Provider Demographics
NPI:1598877540
Name:CLINTON URGENT CARE LLC
Entity Type:Organization
Organization Name:CLINTON URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:JENSSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-592-9113
Mailing Address - Street 1:1004 BEAMAN ST
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:NC
Mailing Address - Zip Code:28328-2329
Mailing Address - Country:US
Mailing Address - Phone:910-592-9113
Mailing Address - Fax:910-590-0050
Practice Address - Street 1:1004 BEAMAN ST
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:NC
Practice Address - Zip Code:28328-2329
Practice Address - Country:US
Practice Address - Phone:910-592-9113
Practice Address - Fax:910-590-0050
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2008-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC790106FMedicaid
NC790106FMedicaid