MEDICARE: WISE CLINICAL CARE ASSOCIATES

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QU0200X	Urgent Care Clinic/Center

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0047SH	OTHER	TX	BCBSTX
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1386112506
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WISE CLINICAL CARE ASSOCIATES

Provider Business Mailing Address
First Line	:	PO BOX 2078
Second Line	:
City	:	DECATUR
State	:	TX
Zip	:	76234-6156
Country	:	US
Telephone Number	:	817-500-9636
Fax Number	:	817-439-8107

Provider Business Practice Location Address
First Line	:	2432 AVONDALE HASLET RD STE 100
Second Line	:
City	:	HASLET
State	:	TX
Zip	:	76052-3446
Country	:	US
Telephone Number	:	817-500-9636
Fax Number	:	817-439-8107

Authorized Official
Title or Position	:	CFO
Name	:	BRIAN TODD SCROGGINS
Credential	:
Telephone Number	:	940-626-1228

Provider Enumeration Date	:	11/06/2018
Last Update Date	:	11/16/2020

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