Provider Demographics
NPI:1417093857
Name:WYNN HABERSHAM COMMUNITY CLINIC INC
Entity Type:Organization
Organization Name:WYNN HABERSHAM COMMUNITY CLINIC INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:H
Authorized Official - Last Name:WILKENS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-784-5110
Mailing Address - Street 1:PO BOX 946
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-0946
Mailing Address - Country:US
Mailing Address - Phone:423-784-0269
Mailing Address - Fax:
Practice Address - Street 1:1037 STINKING CREEK RD
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-6108
Practice Address - Country:US
Practice Address - Phone:423-784-5110
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-30
Last Update Date:2007-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN443872Medicare ID - Type Unspecified
TN3380567Medicare PIN