Provider Demographics
NPI:1043781420
Name:CLARKSTON PRIMARY & URGENT CARE, LLC
Entity Type:Organization
Organization Name:CLARKSTON PRIMARY & URGENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MS
Authorized Official - First Name:ETSUBDENKE
Authorized Official - Middle Name:
Authorized Official - Last Name:AREAYA
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-C
Authorized Official - Phone:678-763-2247
Mailing Address - Street 1:4600 E PONCE DE LEON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:CLARKSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30021-1839
Mailing Address - Country:US
Mailing Address - Phone:770-703-5408
Mailing Address - Fax:877-779-5837
Practice Address - Street 1:4600 E PONCE DE LEON AVE STE A
Practice Address - Street 2:
Practice Address - City:CLARKSTON
Practice Address - State:GA
Practice Address - Zip Code:30021-1839
Practice Address - Country:US
Practice Address - Phone:770-703-5408
Practice Address - Fax:877-779-5837
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty