Provider Demographics
NPI:1043448848
Name:URGENT CARE BANKS CROSSING LLC
Entity Type:Organization
Organization Name:URGENT CARE BANKS CROSSING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:A
Authorized Official - Last Name:BROOKSHIRE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-336-0074
Mailing Address - Street 1:PO BOX 1055
Mailing Address - Street 2:415 B POTTERY FACTORY DR
Mailing Address - City:COMMERCE
Mailing Address - State:GA
Mailing Address - Zip Code:30529-0020
Mailing Address - Country:US
Mailing Address - Phone:706-336-0074
Mailing Address - Fax:706-336-0079
Practice Address - Street 1:415 B POTTERY FACTORY DR
Practice Address - Street 2:
Practice Address - City:COMMERCE
Practice Address - State:GA
Practice Address - Zip Code:30529-6682
Practice Address - Country:US
Practice Address - Phone:706-336-0074
Practice Address - Fax:706-336-0079
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-06-30
Last Update Date:2010-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049138261QM1300X, 261QP2300X, 261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA134759118OtherMEDICAID REFERENCE NUMBER
GA971545216BMedicaid
GA1386802155OtherNPI 1386802155
GA1386802155OtherNPI 1386802155
202G701113Medicare PIN
GA02BBGNJMedicare PIN