Provider Demographics
NPI:1710209234
Name:SAMPSON REGIONAL PROFESSIONAL SERVICES LLC
Entity Type:Organization
Organization Name:SAMPSON REGIONAL PROFESSIONAL SERVICES LLC
Other - Org Name:CLINTON URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HUNTER
Authorized Official - Middle Name:
Authorized Official - Last Name:BALLTZGLIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-590-8755
Mailing Address - Street 1:PO BOX 890315
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28289-0315
Mailing Address - Country:US
Mailing Address - Phone:910-592-8511
Mailing Address - Fax:910-592-5461
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:2010-02-25
Last Update Date:2017-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC99999207Q00000X, 363A00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty