=====================================================
General NPI Number Information
=====================================================
NPI Number | 1922427806
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PROFESSIONAL URGENT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2014
-----------------------------------------------------
Last Update Date | 10/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6055 N MAIN STREET RD
-----------------------------------------------------
City | WEBB CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64870-7219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 620-762-3809
-----------------------------------------------------
Fax | 620-674-3808
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6031 N MAIN STREET RD # 395
-----------------------------------------------------
City | WEBB CITY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64870-7219
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-206-0900
-----------------------------------------------------
Fax | 417-206-0907
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | APRN
-----------------------------------------------------
Name | MRS. ELESHA BROOKE DRAEGER
-----------------------------------------------------
Credential | APRN
-----------------------------------------------------
Telephone | 620-762-3809
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number | 20000152478
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------