Provider Demographics
NPI:1003414442
Name:GACHUGU MEDICAL CLINIC
Entity Type:Organization
Organization Name:GACHUGU MEDICAL CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED OFFICIAL/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:WILSON
Authorized Official - Middle Name:GACHUGU
Authorized Official - Last Name:NDUNGU
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:618-917-9463
Mailing Address - Street 1:1 E FERGUSON AVE
Mailing Address - Street 2:
Mailing Address - City:WOOD RIVER
Mailing Address - State:IL
Mailing Address - Zip Code:62095-1903
Mailing Address - Country:US
Mailing Address - Phone:618-917-9464
Mailing Address - Fax:
Practice Address - Street 1:1 E FERGUSON AVE
Practice Address - Street 2:
Practice Address - City:WOOD RIVER
Practice Address - State:IL
Practice Address - Zip Code:62095-1903
Practice Address - Country:US
Practice Address - Phone:618-251-8138
Practice Address - Fax:618-251-8140
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-16
Last Update Date:2020-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty