Provider Demographics
NPI:1346986015
Name:FORT PAYNE URGENT CARE, LLC
Entity Type:Organization
Organization Name:FORT PAYNE URGENT CARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LUIZ
Authorized Official - Middle Name:
Authorized Official - Last Name:JUAN
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:256-979-1990
Mailing Address - Street 1:100 FOREST AVE NW
Mailing Address - Street 2:
Mailing Address - City:FORT PAYNE
Mailing Address - State:AL
Mailing Address - Zip Code:35967-2054
Mailing Address - Country:US
Mailing Address - Phone:256-979-1990
Mailing Address - Fax:256-979-1992
Practice Address - Street 1:2605 GAULT AVE N STE 200
Practice Address - Street 2:
Practice Address - City:FORT PAYNE
Practice Address - State:AL
Practice Address - Zip Code:35967-3700
Practice Address - Country:US
Practice Address - Phone:256-979-1990
Practice Address - Fax:356-979-1992
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-06
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute CareGroup - Single Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty