Provider Demographics
NPI:1629191788
Name:FLAGSTAFF WALK IN CLINIC LLC
Entity Type:Organization
Organization Name:FLAGSTAFF WALK IN CLINIC LLC
Other - Org Name:WALK IN MEDICAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KURT
Authorized Official - Middle Name:
Authorized Official - Last Name:PETRIE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:928-527-1920
Mailing Address - Street 1:1110 E ROUTE 66 STE 100
Mailing Address - Street 2:
Mailing Address - City:FLAGSTAFF
Mailing Address - State:AZ
Mailing Address - Zip Code:86001-4748
Mailing Address - Country:US
Mailing Address - Phone:928-527-1920
Mailing Address - Fax:
Practice Address - Street 1:1110 E ROUTE 66 STE 100
Practice Address - Street 2:
Practice Address - City:FLAGSTAFF
Practice Address - State:AZ
Practice Address - Zip Code:86001-4748
Practice Address - Country:US
Practice Address - Phone:928-527-1920
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-06
Last Update Date:2008-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZOTC3956261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ62879Medicare PIN
AZ5377530001Medicare NSC