Provider Demographics
NPI:1679216618
Name:WAYSPRING CLINIC DE LLC
Entity Type:Organization
Organization Name:WAYSPRING CLINIC DE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF LEGAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:ALICE
Authorized Official - Middle Name:
Authorized Official - Last Name:HEYWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-345-3555
Mailing Address - Street 1:209 10TH AVE S STE 350
Mailing Address - Street 2:
Mailing Address - City:NASHVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37203-4166
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2055 LIMESTONE RD STE 117
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19808-5536
Practice Address - Country:US
Practice Address - Phone:615-345-3555
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AXIAL HEALTHCARE MANAGEMENT, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-04-18
Last Update Date:2023-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RA0401XAllopathic & Osteopathic PhysiciansInternal MedicineAddiction MedicineGroup - Multi-Specialty