Provider Demographics
NPI:1578087755
Name:CLINIC W LLC
Entity Type:Organization
Organization Name:CLINIC W LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE MEMBER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:S
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:205-383-5336
Mailing Address - Street 1:102 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:CLANTON
Mailing Address - State:AL
Mailing Address - Zip Code:35045-2332
Mailing Address - Country:US
Mailing Address - Phone:205-287-3900
Mailing Address - Fax:888-300-4079
Practice Address - Street 1:102 MEDICAL CENTER DR
Practice Address - Street 2:
Practice Address - City:CLANTON
Practice Address - State:AL
Practice Address - Zip Code:35045-2332
Practice Address - Country:US
Practice Address - Phone:205-383-5336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-07-31
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL26067207R00000X
207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty