MEDICARE: WALLACE URGENT CARE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	363A00000X	Physician Assistant
2	363L00000X	Nurse Practitioner
3	207R00000X	Internal Medicine Physician

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	01736	OTHER	NC	NCBCBS PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1841259025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WALLACE URGENT CARE LLC

Provider Business Mailing Address
First Line	:	112 MEDICAL VILLAGE DR
Second Line	:	UNIT F
City	:	WALLACE
State	:	NC
Zip	:	28466-9999
Country	:	US
Telephone Number	:	910-552-1580
Fax Number	:	910-665-1780

Provider Business Practice Location Address
First Line	:	112 MEDICAL VILLAGE DR
Second Line	:	UNIT F
City	:	WALLACE
State	:	NC
Zip	:	28466-9999
Country	:	US
Telephone Number	:	910-552-1580
Fax Number	:	910-665-1780

Authorized Official
Title or Position	:	OWNER
Name	:	DR. KAMRAN GOUDARZI
Credential	:	M.D.
Telephone Number	:	910-552-1580

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	06/24/2025

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Directions to “WALLACE URGENT CARE LLC ” Practice Location

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