Healthcare Provider Details

I. General information

NPI: 1841259025
Provider Name (Legal Business Name): WALLACE URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2006
Last Update Date: 06/24/2025
Certification Date: 06/24/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

112 MEDICAL VILLAGE DR UNIT F
WALLACE NC
28466-9999
US

IV. Provider business mailing address

112 MEDICAL VILLAGE DR UNIT F
WALLACE NC
28466-9999
US

V. Phone/Fax

Practice location:
  • Phone: 910-552-1580
  • Fax: 910-665-1780
Mailing address:
  • Phone: 910-552-1580
  • Fax: 910-665-1780

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: DR. KAMRAN GOUDARZI
Title or Position: OWNER
Credential: M.D.
Phone: 910-552-1580