Provider Demographics
NPI:1063617967
Name:EXPRESS URGENT CARE
Entity type:Organization
Organization Name:EXPRESS URGENT CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:DANIEL
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:360-923-1111
Mailing Address - Street 1:130 MARVIN RD SE STE 112
Mailing Address - Street 2:
Mailing Address - City:LACEY
Mailing Address - State:WA
Mailing Address - Zip Code:98503-6101
Mailing Address - Country:US
Mailing Address - Phone:360-923-1111
Mailing Address - Fax:360-455-8677
Practice Address - Street 1:130 MARVIN RD SE STE 112
Practice Address - Street 2:
Practice Address - City:LACEY
Practice Address - State:WA
Practice Address - Zip Code:98503-6101
Practice Address - Country:US
Practice Address - Phone:360-923-1111
Practice Address - Fax:360-455-8677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-19
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOP00001758305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAH48337Medicare UPIN
WAG8806633Medicare PIN