MEDICARE: PROFESSIONAL URGENT CARE LLC

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	20000152478	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1922427806
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PROFESSIONAL URGENT CARE LLC

Provider Business Mailing Address
First Line	:	6031 N MAIN STREET RD # 395
Second Line	:
City	:	WEBB CITY
State	:	MO
Zip	:	64870-7219
Country	:	US
Telephone Number	:	417-206-0900
Fax Number	:	417-206-0907

Provider Business Practice Location Address
First Line	:	6055 N MAIN STREET RD
Second Line	:
City	:	WEBB CITY
State	:	MO
Zip	:	64870-7219
Country	:	US
Telephone Number	:	620-762-3809
Fax Number	:	620-674-3808

Authorized Official
Title or Position	:	APRN
Name	:	MRS. ELESHA BROOKE DRAEGER
Credential	:	APRN
Telephone Number	:	620-762-3809

Provider Enumeration Date	:	04/08/2014
Last Update Date	:	10/03/2014

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