Provider Demographics
NPI:1982908877
Name:PETAL URGENT CARE LLC
Entity Type:Organization
Organization Name:PETAL URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RONNIE
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:601-336-5393
Mailing Address - Street 1:PO BOX 1248
Mailing Address - Street 2:
Mailing Address - City:OCEAN SPRINGS
Mailing Address - State:MS
Mailing Address - Zip Code:39566-1248
Mailing Address - Country:US
Mailing Address - Phone:601-336-5393
Mailing Address - Fax:601-602-4681
Practice Address - Street 1:1272 EVELYN GANDY PKWY STE 60
Practice Address - Street 2:
Practice Address - City:PETAL
Practice Address - State:MS
Practice Address - Zip Code:39465-3953
Practice Address - Country:US
Practice Address - Phone:707-319-5068
Practice Address - Fax:601-602-4681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-01-06
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS03704755Medicaid
MS03704755Medicaid