Provider Demographics
NPI:1306856174
Name:WYNNTON FAMILY CLINIC, LLC
Entity Type:Organization
Organization Name:WYNNTON FAMILY CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DR.
Authorized Official - Prefix:
Authorized Official - First Name:ASMA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:706-320-9355
Mailing Address - Street 1:2032 WYNNTON RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLUMBUS
Mailing Address - State:GA
Mailing Address - Zip Code:31906-2448
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2032 WYNNTON RD
Practice Address - Street 2:SUITE B
Practice Address - City:COLUMBUS
Practice Address - State:GA
Practice Address - Zip Code:31906-2448
Practice Address - Country:US
Practice Address - Phone:706-320-9355
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-08
Last Update Date:2014-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAGRP7007Medicare ID - Type Unspecified