Provider Demographics
NPI:1083256804
Name:THELWELL IMMEDIATE CARE CLINIC INC
Entity Type:Organization
Organization Name:THELWELL IMMEDIATE CARE CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN ASSISTANT
Authorized Official - Prefix:
Authorized Official - First Name:ENOMA
Authorized Official - Middle Name:
Authorized Official - Last Name:EVBUOMWAN
Authorized Official - Suffix:
Authorized Official - Credentials:PA-C
Authorized Official - Phone:646-402-1122
Mailing Address - Street 1:1400 VETERANS MEMORIAL HIGHWAY SE SUITE 134 #176
Mailing Address - Street 2:
Mailing Address - City:MABLETON
Mailing Address - State:GA
Mailing Address - Zip Code:30126
Mailing Address - Country:US
Mailing Address - Phone:646-402-1122
Mailing Address - Fax:
Practice Address - Street 1:1400 VETERANS MEMORIAL HIGHWAY SE SUITE 134 #176
Practice Address - Street 2:
Practice Address - City:MABLETON
Practice Address - State:GA
Practice Address - Zip Code:30126
Practice Address - Country:US
Practice Address - Phone:646-402-1122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-10-14
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty
No261QV0200XAmbulatory Health Care FacilitiesClinic/CenterVAGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty