Provider Demographics
NPI:1710231576
Name:CLINTON WELLNESS CENTER LLC
Entity Type:Organization
Organization Name:CLINTON WELLNESS CENTER LLC
Other - Org Name:ICARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SHINITA
Authorized Official - Middle Name:REED
Authorized Official - Last Name:DUDLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:601-714-8180
Mailing Address - Street 1:514 E WOODROW WILSON AVE
Mailing Address - Street 2:SUITE C
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39216-4538
Mailing Address - Country:US
Mailing Address - Phone:601-714-8180
Mailing Address - Fax:601-922-9900
Practice Address - Street 1:514 E WOODROW WILSON AVE
Practice Address - Street 2:SUITE C
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39216-4538
Practice Address - Country:US
Practice Address - Phone:601-714-8180
Practice Address - Fax:601-922-9900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-01
Last Update Date:2012-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS18239207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS07033864Medicaid
MS512I080023OtherMISSISSIPPI MEDICARE NUMBER
TN1413306OtherBCBS OF TENN
MS587159423IOtherBCBS
TN1413306OtherBCBS OF TENN