Provider Demographics
NPI:1508518002
Name:CLINIC652 LLC
Entity Type:Organization
Organization Name:CLINIC652 LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER/CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:WARREN
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:O'MEARA-DATES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-418-4005
Mailing Address - Street 1:417 TAYLOR ST
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35903-2557
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2600 E MEIGHAN BLVD
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35903-1924
Practice Address - Country:US
Practice Address - Phone:256-418-4005
Practice Address - Fax:256-399-0102
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-01-25
Last Update Date:2022-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty