Provider Demographics
NPI:1073909859
Name:NELLIE GAIL URGENT CARE MEDICAL CORP
Entity Type:Organization
Organization Name:NELLIE GAIL URGENT CARE MEDICAL CORP
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:
Authorized Official - First Name:JACK
Authorized Official - Middle Name:BAILEY
Authorized Official - Last Name:VU
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:949-600-1907
Mailing Address - Street 1:27001 MOULTON PKWY
Mailing Address - Street 2:SUITE A-102
Mailing Address - City:LAGUNA HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:92656-3626
Mailing Address - Country:US
Mailing Address - Phone:949-600-1907
Mailing Address - Fax:949-600-1912
Practice Address - Street 1:27001 MOULTON PKWY
Practice Address - Street 2:SUITE A-102
Practice Address - City:LAGUNA HILLS
Practice Address - State:CA
Practice Address - Zip Code:92656-3626
Practice Address - Country:US
Practice Address - Phone:949-600-1907
Practice Address - Fax:949-600-1912
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-09-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X
CAFNP544683261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty