Provider Demographics
NPI:1649589466
Name:SOUTHEAST URGENT CARE LLC
Entity Type:Organization
Organization Name:SOUTHEAST URGENT CARE LLC
Other - Org Name:SOUTHEAST URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOSTER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:815-713-2600
Mailing Address - Street 1:2118 SCENIC HWY N
Mailing Address - Street 2:SUITE H-I
Mailing Address - City:SNELLVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30078-2633
Mailing Address - Country:US
Mailing Address - Phone:770-558-6017
Mailing Address - Fax:
Practice Address - Street 1:2118 SCENIC HWY N
Practice Address - Street 2:SUITE H-I
Practice Address - City:SNELLVILLE
Practice Address - State:GA
Practice Address - Zip Code:30078-2633
Practice Address - Country:US
Practice Address - Phone:770-558-6017
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-28
Last Update Date:2011-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202G704101OtherGROUP PTAN
GA202G704101OtherGROUP PTAN