Provider Demographics
NPI:1669463584
Name:WALLEY CLINIC PA
Entity Type:Organization
Organization Name:WALLEY CLINIC PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:ELETHA
Authorized Official - Middle Name:JANE
Authorized Official - Last Name:JENKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:601-735-2401
Mailing Address - Street 1:920 MATTHEW DR
Mailing Address - Street 2:STE A
Mailing Address - City:WAYNESBORO
Mailing Address - State:MS
Mailing Address - Zip Code:39367-2567
Mailing Address - Country:US
Mailing Address - Phone:601-735-2401
Mailing Address - Fax:601-735-5205
Practice Address - Street 1:920 MATTHEW DR
Practice Address - Street 2:STE A
Practice Address - City:WAYNESBORO
Practice Address - State:MS
Practice Address - Zip Code:39367-2567
Practice Address - Country:US
Practice Address - Phone:601-735-2401
Practice Address - Fax:601-735-5205
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-31
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09011779Medicaid
C00213Medicare PIN
258986Medicare Oscar/Certification