Provider Demographics
NPI:1205436516
Name:COUNTY LINE URGENT CARE LLC
Entity type:Organization
Organization Name:COUNTY LINE URGENT CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:NORMAN
Authorized Official - Middle Name:
Authorized Official - Last Name:INDICH
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:732-730-9111
Mailing Address - Street 1:603 W COUNTY LINE RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-1216
Mailing Address - Country:US
Mailing Address - Phone:732-730-9111
Mailing Address - Fax:732-595-1330
Practice Address - Street 1:603 W COUNTY LINE RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-1216
Practice Address - Country:US
Practice Address - Phone:732-730-9111
Practice Address - Fax:732-595-1330
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care