=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093184376
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEALTHCARE SOLUTIONS WALK-IN CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2015
-----------------------------------------------------
Last Update Date | 09/17/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 CUMBERLAND ST
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301-7020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-678-5177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 705 CUMBERLAND ST
-----------------------------------------------------
City | FAYETTEVILLE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28301-7020
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 910-678-5177
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELIZABETH SMITH
-----------------------------------------------------
Credential | PA
-----------------------------------------------------
Telephone | 678-517-7775
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 98395
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 98395
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------