Provider Demographics
NPI:1659682938
Name:WALK IN MEDICAL CLINIC
Entity Type:Organization
Organization Name:WALK IN MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:L
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-449-2216
Mailing Address - Street 1:900 RAIN FOREST PKWY STE B
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MO
Mailing Address - Zip Code:65202-3796
Mailing Address - Country:US
Mailing Address - Phone:573-449-2216
Mailing Address - Fax:573-449-2217
Practice Address - Street 1:900 RAIN FOREST PKWY STE B
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MO
Practice Address - Zip Code:65202-3796
Practice Address - Country:US
Practice Address - Phone:573-449-2216
Practice Address - Fax:573-449-2217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-01
Last Update Date:2010-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO36389261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOE59586Medicare UPIN