Provider Demographics
NPI:1508120387
Name:WELL CHILD OF MISSISSIPPI LLC
Entity Type:Organization
Organization Name:WELL CHILD OF MISSISSIPPI LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KAREN
Authorized Official - Middle Name:J
Authorized Official - Last Name:PEASE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:901-728-5858
Mailing Address - Street 1:1785 NONCONNAH BLVD STE 120
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38132-2112
Mailing Address - Country:US
Mailing Address - Phone:901-728-5858
Mailing Address - Fax:901-274-5858
Practice Address - Street 1:1785 NONCONNAH BLVD STE 120
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38132-2112
Practice Address - Country:US
Practice Address - Phone:901-728-5858
Practice Address - Fax:901-274-5858
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WCI MANAGEMENT SERVICES LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-06-27
Last Update Date:2014-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN13712207Q00000X
261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty