1699946103 NPI number — COMMUNITY CARE CLINIC LLC

Table of content: (NPI 1699946103)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1699946103 NPI number — COMMUNITY CARE CLINIC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COMMUNITY CARE CLINIC LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1699946103
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 306
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OCOEE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37361-0306
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-338-7434
Provider Business Mailing Address Fax Number:
423-338-7436

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4867 HIGHWAY 411
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CLEVELAND
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37323-5360
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-338-7434
Provider Business Practice Location Address Fax Number:
423-338-7436
Provider Enumeration Date:
03/13/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BECK
Authorized Official First Name:
WENDY
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRACTICIONER/OWNER
Authorized Official Telephone Number:
423-338-7434

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  F0906005 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)