Provider Demographics
NPI:1407207814
Name:WAYNESBORO CLINIC, LLC
Entity Type:Organization
Organization Name:WAYNESBORO CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:HOWARD
Authorized Official - Last Name:POLK
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:931-722-3677
Mailing Address - Street 1:PO BOX 778
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-0778
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:206 CLIFTON TPKE
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485-2301
Practice Address - Country:US
Practice Address - Phone:931-722-3677
Practice Address - Fax:931-722-4677
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-27
Last Update Date:2016-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNDO127207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty