Provider Demographics
NPI:1679246987
Name:SOUTHERN HEALTH & WELLNESS CLINIC
Entity Type:Organization
Organization Name:SOUTHERN HEALTH & WELLNESS CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:BOLING
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:731-784-5080
Mailing Address - Street 1:3519 CHERE CAROL RD
Mailing Address - Street 2:
Mailing Address - City:HUMBOLDT
Mailing Address - State:TN
Mailing Address - Zip Code:38343-3638
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3519 CHERE CAROL RD
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343-3638
Practice Address - Country:US
Practice Address - Phone:731-414-9051
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-08-01
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care