=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194062406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | URGENT CARES OF AMERICA NORTH CAROLINA INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/07/2013
-----------------------------------------------------
Last Update Date | 09/19/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 310 S STRATFORD RD 120
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27103-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-714-5399
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5626 OBERLIN DR 110
-----------------------------------------------------
City | SAN DIEGO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92121-1705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VP OPS
-----------------------------------------------------
Name | KENNY HEINE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 858-964-1506
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332900000X
-----------------------------------------------------
Taxonomy Name | Non-Pharmacy Dispensing Site
-----------------------------------------------------
License Number | 103225
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------