Provider Demographics
NPI:1275587768
Name:URGENT CARE AT LAKE LUCILLE INC
Entity Type:Organization
Organization Name:URGENT CARE AT LAKE LUCILLE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FINANCIAL OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:R
Authorized Official - Last Name:VAROSI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:907-373-4200
Mailing Address - Street 1:185 E PARKS HWY
Mailing Address - Street 2:
Mailing Address - City:WASILLA
Mailing Address - State:AK
Mailing Address - Zip Code:99654-7038
Mailing Address - Country:US
Mailing Address - Phone:907-373-4203
Mailing Address - Fax:907-373-4201
Practice Address - Street 1:185 E PARKS HWY
Practice Address - Street 2:
Practice Address - City:WASILLA
Practice Address - State:AK
Practice Address - Zip Code:99654-7038
Practice Address - Country:US
Practice Address - Phone:907-373-4203
Practice Address - Fax:907-373-4201
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-20
Last Update Date:2010-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK3064207Q00000X, 261QU0200X
AK157496261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMDG043Medicaid
AKMDG496Medicaid
AK0000WCQHGMedicare ID - Type UnspecifiedGROUP PROVIDER NUMBER
AKMDG496Medicaid