1710231576 NPI number — CLINTON WELLNESS CENTER LLC

Table of content: (NPI 1710231576)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710231576 NPI number — CLINTON WELLNESS CENTER LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLINTON WELLNESS CENTER 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:
ICARE
Provider Other Organization Name Type Code:
3
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:
1710231576
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/01/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
514 E WOODROW WILSON AVE
Provider Second Line Business Mailing Address:
SUITE C
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39216-4538
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-714-8180
Provider Business Mailing Address Fax Number:
601-922-9900

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
514 E WOODROW WILSON AVE
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
39216-4538
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
601-714-8180
Provider Business Practice Location Address Fax Number:
601-922-9900
Provider Enumeration Date:
11/01/2012

Additional Information

Authorized Official

Authorized Official Last Name:
DUDLEY
Authorized Official First Name:
SHINITA
Authorized Official Middle Name:
REED
Authorized Official Title or Position:
PHYSICIAN
Authorized Official Telephone Number:
601-714-8180

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  18239 , registered in the state of MS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 07033864 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 512I080023 . This is a "MISSISSIPPI MEDICARE NUMBER" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".
  • Identifier: 1413306 . This is a "BCBS OF TENN" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 587159423I . This is a "BCBS" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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