Provider Demographics
NPI:1639295074
Name:FIRST CARE MEDICAL CLINIC
Entity Type:Organization
Organization Name:FIRST CARE MEDICAL CLINIC
Other - Org Name:FIRST CARE MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:VENNY
Authorized Official - Middle Name:O
Authorized Official - Last Name:OKWARA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:704-291-9267
Mailing Address - Street 1:404 S SUTHERLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:NC
Mailing Address - Zip Code:28112-5060
Mailing Address - Country:US
Mailing Address - Phone:704-291-9267
Mailing Address - Fax:
Practice Address - Street 1:2938 THE PLZ
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-2463
Practice Address - Country:US
Practice Address - Phone:704-378-4122
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-21
Last Update Date:2011-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207P00000XAllopathic & Osteopathic PhysiciansEmergency MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Multi-Specialty
No2080A0000XAllopathic & Osteopathic PhysiciansPediatricsAdolescent MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89013J4Medicaid
NC2326436OtherMEDIACARE GROUP #
NC89013J4Medicaid