Healthcare Provider Details

I. General information

NPI: 1215561998
Provider Name (Legal Business Name): PACIFIC NORTHWEST URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2020
Last Update Date: 06/24/2020
Certification Date: 06/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 OCEAN BEACH HWY STE 110
LONGVIEW WA
98632-4171
US

IV. Provider business mailing address

6344 SE 87TH AVE
PORTLAND OR
97266-5330
US

V. Phone/Fax

Practice location:
  • Phone: 360-648-8860
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: ALOYSIUS FOBI
Title or Position: SOLE OWNER
Credential: MD
Phone: 503-953-2391