Provider Demographics
NPI:1386826279
Name:CLINTON WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CLINTON WELLNESS CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL BILLER
Authorized Official - Prefix:
Authorized Official - First Name:TRICIA
Authorized Official - Middle Name:B
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:BILLER
Authorized Official - Phone:601-878-6945
Mailing Address - Street 1:PO BOX 1338
Mailing Address - Street 2:
Mailing Address - City:CLINTON
Mailing Address - State:MS
Mailing Address - Zip Code:39060-1338
Mailing Address - Country:US
Mailing Address - Phone:601-488-6187
Mailing Address - Fax:601-878-2011
Practice Address - Street 1:703 HIGHWAY 80 W STE A
Practice Address - Street 2:
Practice Address - City:CLINTON
Practice Address - State:MS
Practice Address - Zip Code:39056-4107
Practice Address - Country:US
Practice Address - Phone:601-488-6187
Practice Address - Fax:601-878-2011
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-03
Last Update Date:2009-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07033864Medicaid
MS587159423IOtherBCBS
MSI00204Medicare UPIN
MS512G70020Medicare PIN