Provider Demographics
NPI:1073754636
Name:WHITEVILLE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:WHITEVILLE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DNP
Authorized Official - Prefix:
Authorized Official - First Name:DEE
Authorized Official - Middle Name:
Authorized Official - Last Name:BLAKNEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-626-6626
Mailing Address - Street 1:2060 US HIGHWAY 64
Mailing Address - Street 2:SUITE C
Mailing Address - City:WHITEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38075-7476
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2060 US HIGHWAY 64
Practice Address - Street 2:SUITE C
Practice Address - City:WHITEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38075-7476
Practice Address - Country:US
Practice Address - Phone:901-626-6626
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-03-11
Last Update Date:2009-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty