Provider Demographics
NPI:1073703591
Name:WELL CHILD INC.
Entity Type:Organization
Organization Name:WELL CHILD INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTIONER
Authorized Official - Prefix:MS
Authorized Official - First Name:MALLORY
Authorized Official - Middle Name:I
Authorized Official - Last Name:WILBON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-728-5858
Mailing Address - Street 1:2158 UNION AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38104-4297
Mailing Address - Country:US
Mailing Address - Phone:901-728-5858
Mailing Address - Fax:901-274-5858
Practice Address - Street 1:2158 UNION AVE STE 100
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38104-4297
Practice Address - Country:US
Practice Address - Phone:901-728-5858
Practice Address - Fax:901-274-5858
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELL CHILD INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-07-31
Last Update Date:2007-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN105563140N1450X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3140N1450XNursing & Custodial Care FacilitiesSkilled Nursing FacilityNursing Care, Pediatric
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN5440184Medicaid