Provider Demographics
NPI:1871816884
Name:PROVIDENCE IMMEDIATE CARE INCORPORATED
Entity Type:Organization
Organization Name:PROVIDENCE IMMEDIATE CARE INCORPORATED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:EWANE
Authorized Official - Middle Name:
Authorized Official - Last Name:NGONE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:678-907-2086
Mailing Address - Street 1:1002 OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:VILLA RICA
Mailing Address - State:GA
Mailing Address - Zip Code:30180-5804
Mailing Address - Country:US
Mailing Address - Phone:678-907-2086
Mailing Address - Fax:678-840-8742
Practice Address - Street 1:1002 OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-5804
Practice Address - Country:US
Practice Address - Phone:678-907-2086
Practice Address - Fax:678-840-8742
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-04
Last Update Date:2010-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care