Provider Demographics
NPI:1124311550
Name:URGENT CARE CLINIC SOUTH
Entity type:Organization
Organization Name:URGENT CARE CLINIC SOUTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KARLEEN
Authorized Official - Middle Name:RAE
Authorized Official - Last Name:KITZMILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:503-588-1234
Mailing Address - Street 1:3777 COMMERCIAL ST SE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97302-3832
Mailing Address - Country:US
Mailing Address - Phone:503-588-1234
Mailing Address - Fax:503-371-8662
Practice Address - Street 1:3777 COMMERCIAL ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97302-3832
Practice Address - Country:US
Practice Address - Phone:503-588-1234
Practice Address - Fax:503-371-8662
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-18
Last Update Date:2011-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD10412174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty