Provider Demographics
NPI:1124410410
Name:CLINTON WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CLINTON WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:MARCO
Authorized Official - Middle Name:
Authorized Official - Last Name:MORAN
Authorized Official - Suffix:
Authorized Official - Credentials:DPH
Authorized Official - Phone:318-791-3765
Mailing Address - Street 1:PO BOX 59294
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39284-9294
Mailing Address - Country:US
Mailing Address - Phone:318-791-3765
Mailing Address - Fax:877-747-5326
Practice Address - Street 1:322 HIGHWAY 80 E
Practice Address - Street 2:SUITE D
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4726
Practice Address - Country:US
Practice Address - Phone:318-791-3765
Practice Address - Fax:877-747-5326
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty