Provider Demographics
NPI:1932860418
Name:PREMIERE ONLINE URGENT CARE
Entity Type:Organization
Organization Name:PREMIERE ONLINE URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAREKIA
Authorized Official - Middle Name:
Authorized Official - Last Name:DASH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:470-483-2992
Mailing Address - Street 1:901 SUMMERS AVE
Mailing Address - Street 2:
Mailing Address - City:ORANGEBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29115-4931
Mailing Address - Country:US
Mailing Address - Phone:470-483-2992
Mailing Address - Fax:
Practice Address - Street 1:901 SUMMERS AVE
Practice Address - Street 2:
Practice Address - City:ORANGEBURG
Practice Address - State:SC
Practice Address - Zip Code:29115-4931
Practice Address - Country:US
Practice Address - Phone:470-483-2992
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-06
Last Update Date:2022-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0006XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Fertility Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA061920860Medicaid