Provider Demographics
NPI:1467601765
Name:COLLEGE DRIVE URGENT CARE LLC
Entity Type:Organization
Organization Name:COLLEGE DRIVE URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT & CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:JULIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:480-776-1600
Mailing Address - Street 1:2550 N. THUNDERBIRD CIRCLE
Mailing Address - Street 2:SUITE 303
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85215-1219
Mailing Address - Country:US
Mailing Address - Phone:480-776-1600
Mailing Address - Fax:480-776-0025
Practice Address - Street 1:4140A LARAMIE ST
Practice Address - Street 2:
Practice Address - City:CHEYENNE
Practice Address - State:WY
Practice Address - Zip Code:82001-1969
Practice Address - Country:US
Practice Address - Phone:307-637-2800
Practice Address - Fax:307-637-2867
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-09-11
Last Update Date:2021-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
WY315527OtherBSWY
WY314332OtherBLUE CROSS BLUE SHIELD
WY314338OtherBSWY
WY314333OtherBLUE CROSS BLUE SHIELD
WYW20459Medicare PIN
WYW21610Medicare PIN
WY314333OtherBLUE CROSS BLUE SHIELD
WY315527OtherBSWY
WYW20702Medicare PIN
WYS62288Medicare UPIN
WY6256150001Medicare NSC
A73012Medicare UPIN