Provider Demographics
NPI:1063865343
Name:WJL PODIATRY CLINIC LLC
Entity Type:Organization
Organization Name:WJL PODIATRY CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIE
Authorized Official - Middle Name:
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:601-355-0026
Mailing Address - Street 1:953 NORTH ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39202-2615
Mailing Address - Country:US
Mailing Address - Phone:601-355-0026
Mailing Address - Fax:
Practice Address - Street 1:953 NORTH ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39202-2615
Practice Address - Country:US
Practice Address - Phone:601-355-0026
Practice Address - Fax:601-355-0069
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-21
Last Update Date:2017-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS80062261QP1100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric