Provider Demographics
NPI:1083160436
Name:NOAH'S ARK URGENT CARE LLC
Entity Type:Organization
Organization Name:NOAH'S ARK URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHARLA
Authorized Official - Middle Name:VERDENE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:470-771-9677
Mailing Address - Street 1:950 EAGLES LANDING PKWY
Mailing Address - Street 2:SUITE 212
Mailing Address - City:STOCKBRIDGE
Mailing Address - State:GA
Mailing Address - Zip Code:30281-7343
Mailing Address - Country:US
Mailing Address - Phone:470-771-9677
Mailing Address - Fax:
Practice Address - Street 1:950 EAGLES LANDING PKWY
Practice Address - Street 2:SUITE 212
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-7343
Practice Address - Country:US
Practice Address - Phone:470-771-9677
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2016-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA003556261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA667084523BMedicaid
GA97WCGBQMedicare PIN
GA667084523BMedicaid