Provider Demographics
NPI:1922427806
Name:PROFESSIONAL URGENT CARE LLC
Entity Type:Organization
Organization Name:PROFESSIONAL URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:APRN
Authorized Official - Prefix:MRS
Authorized Official - First Name:ELESHA
Authorized Official - Middle Name:BROOKE
Authorized Official - Last Name:DRAEGER
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:620-762-3809
Mailing Address - Street 1:6031 N MAIN STREET RD # 395
Mailing Address - Street 2:
Mailing Address - City:WEBB CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64870-7219
Mailing Address - Country:US
Mailing Address - Phone:417-206-0900
Mailing Address - Fax:417-206-0907
Practice Address - Street 1:6055 N MAIN STREET RD
Practice Address - Street 2:
Practice Address - City:WEBB CITY
Practice Address - State:MO
Practice Address - Zip Code:64870-7219
Practice Address - Country:US
Practice Address - Phone:620-762-3809
Practice Address - Fax:620-674-3808
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-08
Last Update Date:2014-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20000152478261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO427487707Medicaid
KS200354220CMedicaid