=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326645573
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PICKENS URGENT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/01/2020
-----------------------------------------------------
Last Update Date | 10/01/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 744 NOAH DR STE 108-109
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30143-8705
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-692-0119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 790 CHAMPIONS CLUB DR
-----------------------------------------------------
City | ALPHARETTA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30004-6955
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 706-692-0119
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | JESUS VAZQUEZ-FIGUEROA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 404-984-8357
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------