Provider Demographics
NPI:1811925092
Name:LINCOLN CITY IMMEDIATE CARE
Entity type:Organization
Organization Name:LINCOLN CITY IMMEDIATE CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF OPERATING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:SHERREL
Authorized Official - Middle Name:A
Authorized Official - Last Name:STEPHENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:540-504-6315
Mailing Address - Street 1:PO BOX 177
Mailing Address - Street 2:
Mailing Address - City:MCMINNVILLE
Mailing Address - State:OR
Mailing Address - Zip Code:97128-0177
Mailing Address - Country:US
Mailing Address - Phone:541-504-6315
Mailing Address - Fax:541-923-4002
Practice Address - Street 1:1105 SE JETTY AVE
Practice Address - Street 2:SUITE C
Practice Address - City:LINCOLN CITY
Practice Address - State:OR
Practice Address - Zip Code:97367-2632
Practice Address - Country:US
Practice Address - Phone:541-994-1727
Practice Address - Fax:541-996-5181
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-28
Last Update Date:2009-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR261QU0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORR117038Medicare PIN