Provider Demographics
NPI:1174864946
Name:CONRAD PEARSON CLINIC
Entity Type:Organization
Organization Name:CONRAD PEARSON CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING SPECIALIST
Authorized Official - Prefix:
Authorized Official - First Name:LINDA
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-252-3411
Mailing Address - Street 1:1325 WOLF PARK DR STE 103
Mailing Address - Street 2:
Mailing Address - City:GERMANTOWN
Mailing Address - State:TN
Mailing Address - Zip Code:38138-1759
Mailing Address - Country:US
Mailing Address - Phone:901-252-3411
Mailing Address - Fax:901-763-4305
Practice Address - Street 1:1325 WOLF PARK DR STE 102
Practice Address - Street 2:
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-1759
Practice Address - Country:US
Practice Address - Phone:901-252-4311
Practice Address - Fax:901-763-4305
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-04
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty