Provider Demographics
NPI:1841259025
Name:WALLACE URGENT CARE LLC
Entity type:Organization
Organization Name:WALLACE URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:KAMRAN
Authorized Official - Middle Name:
Authorized Official - Last Name:GOUDARZI
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:910-552-1580
Mailing Address - Street 1:112 MEDICAL VILLAGE DR
Mailing Address - Street 2:UNIT F
Mailing Address - City:WALLACE
Mailing Address - State:NC
Mailing Address - Zip Code:28466-9999
Mailing Address - Country:US
Mailing Address - Phone:910-552-1580
Mailing Address - Fax:910-665-1780
Practice Address - Street 1:112 MEDICAL VILLAGE DR
Practice Address - Street 2:UNIT F
Practice Address - City:WALLACE
Practice Address - State:NC
Practice Address - Zip Code:28466-9999
Practice Address - Country:US
Practice Address - Phone:910-552-1580
Practice Address - Fax:910-665-1780
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2025-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7901736Medicaid
NC01736OtherNCBCBS PROVIDER NUMBER
NC7901736Medicaid
NC7901736Medicaid
NC=========OtherTAX IDENTIFICATION