Provider Demographics
NPI:1063421469
Name:UNION URGENT CARE LLC
Entity type:Organization
Organization Name:UNION URGENT CARE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SENIOR VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:L
Authorized Official - Last Name:WIENS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:704-355-0648
Mailing Address - Street 1:PO BOX 60777
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0777
Mailing Address - Country:US
Mailing Address - Phone:704-283-8193
Mailing Address - Fax:704-283-7252
Practice Address - Street 1:613 E ROOSEVELT BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-5124
Practice Address - Country:US
Practice Address - Phone:704-283-8193
Practice Address - Fax:704-283-7252
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNION URGENT CARE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-08-05
Last Update Date:2011-09-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017C2OtherBLUE CROSS - BLUE SHIELD
NC5901850Medicaid
NC7705293OtherMEDICAID DME
NC017C2OtherBLUE CROSS - BLUE SHIELD
NC7705293OtherMEDICAID DME
NCDD7921Medicare PIN