Provider Demographics
NPI:1912054792
Name:BEREA URGENT CARE LLC
Entity Type:Organization
Organization Name:BEREA URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:NAWAR
Authorized Official - Middle Name:
Authorized Official - Last Name:SODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:859-985-0302
Mailing Address - Street 1:234 BRENWOOD ST
Mailing Address - Street 2:
Mailing Address - City:BEREA
Mailing Address - State:KY
Mailing Address - Zip Code:40403-1637
Mailing Address - Country:US
Mailing Address - Phone:859-985-0302
Mailing Address - Fax:859-985-0308
Practice Address - Street 1:234 BRENWOOD ST
Practice Address - Street 2:
Practice Address - City:BEREA
Practice Address - State:KY
Practice Address - Zip Code:40403-1637
Practice Address - Country:US
Practice Address - Phone:859-985-0302
Practice Address - Fax:859-985-0308
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-04
Last Update Date:2016-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
No261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent CareGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY18D1046850OtherCLIA
KY65944373Medicaid