Basic Information
Provider Information | |||||||||
NPI: | 1013163690 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | WELLNESS CLINIC AND FAMILY CARE PLLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2410 ENVILLE RD | ||||||||
Address2: |   | ||||||||
City: | HENDERSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383403945 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7319832328 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 21 MERIDIAN SPRINGS DR | ||||||||
Address2: |   | ||||||||
City: | JACKSON | ||||||||
State: | TN | ||||||||
PostalCode: | 383015900 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7312560526 | ||||||||
FaxNumber: | 7312561720 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/14/2008 | ||||||||
LastUpdateDate: | 11/26/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CREECH | ||||||||
AuthorizedOfficialFirstName: | ERIKA | ||||||||
AuthorizedOfficialMiddleName: | HAZARD | ||||||||
AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
AuthorizedOfficialTelephone: | 7319832328 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | MD024799 | TN | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.