=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942875984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELITE URGENT CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2021
-----------------------------------------------------
Last Update Date | 05/21/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136-4 FORUM DR 1018
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29229
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-836-8679
-----------------------------------------------------
Fax | 803-888-2007
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 416 ROYAL LINKS DR STE B
-----------------------------------------------------
City | BLYTHEWOOD
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29016-8390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 803-836-8679
-----------------------------------------------------
Fax | 803-888-2007
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. PAULETTE O RUMPH
-----------------------------------------------------
Credential | FNP-BC
-----------------------------------------------------
Telephone | 803-836-8679
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QM1300X
-----------------------------------------------------
Taxonomy Name | Multi-Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 261QU0200X
-----------------------------------------------------
Taxonomy Name | Urgent Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------