Provider Demographics
NPI:1942469606
Name:THE CHILDREN'S CLINIC OF WEST TENNESSEE P.A.
Entity Type:Organization
Organization Name:THE CHILDREN'S CLINIC OF WEST TENNESSEE P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:LESLIE
Authorized Official - Last Name:SELF
Authorized Official - Suffix:JR
Authorized Official - Credentials:MD
Authorized Official - Phone:731-423-1500
Mailing Address - Street 1:264 COATSLAND DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-3948
Mailing Address - Country:US
Mailing Address - Phone:731-423-1500
Mailing Address - Fax:731-423-0342
Practice Address - Street 1:264 COATSLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-3948
Practice Address - Country:US
Practice Address - Phone:731-423-1500
Practice Address - Fax:731-423-0342
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-06
Last Update Date:2008-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208000000XAllopathic & Osteopathic PhysiciansPediatricsGroup - Single Specialty