Provider Demographics
NPI:1396043691
Name:TRACRW LLC
Entity Type:Organization
Organization Name:TRACRW LLC
Other - Org Name:TREATMENT ROOMS OF AMERICA CRW
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:R
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:901-272-3200
Mailing Address - Street 1:995 S YATES RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38119-0882
Mailing Address - Country:US
Mailing Address - Phone:901-527-7100
Mailing Address - Fax:
Practice Address - Street 1:995 S YATES RD
Practice Address - Street 2:SUITE 1
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38119-0882
Practice Address - Country:US
Practice Address - Phone:901-527-7100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHARLES WALLACE JR MD
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-10
Last Update Date:2011-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center