Provider Demographics
NPI:1063820553
Name:DYERSBURG CLINIC CORP
Entity Type:Organization
Organization Name:DYERSBURG CLINIC CORP
Other - Org Name:HAYWOOD PARK URGENT CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-465-7587
Mailing Address - Street 1:2545 N WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:BROWNSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38012-1610
Mailing Address - Country:US
Mailing Address - Phone:731-772-9042
Mailing Address - Fax:731-772-3937
Practice Address - Street 1:2545 N WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:BROWNSVILLE
Practice Address - State:TN
Practice Address - Zip Code:38012-1610
Practice Address - Country:US
Practice Address - Phone:731-772-9042
Practice Address - Fax:731-772-3937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QU0200XAmbulatory Health Care FacilitiesClinic/CenterUrgent Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3718531Medicaid
TN3718531Medicaid