Provider Demographics
NPI:1013176114
Name:WISDOM HEALTHCARE CLINIC N HEALTHCARE SERVICES INC
Entity type:Organization
Organization Name:WISDOM HEALTHCARE CLINIC N HEALTHCARE SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BADEJO
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:972-436-1811
Mailing Address - Street 1:403 W MAIN ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:LEWISVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75057-3757
Mailing Address - Country:US
Mailing Address - Phone:817-200-6189
Mailing Address - Fax:469-464-4398
Practice Address - Street 1:403 W MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:LEWISVILLE
Practice Address - State:TX
Practice Address - Zip Code:75057-3757
Practice Address - Country:US
Practice Address - Phone:817-200-6189
Practice Address - Fax:469-464-4398
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-03
Last Update Date:2010-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXPA04564207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX198899001Medicaid
TX1067786OtherNCCPA
TXPA04564OtherLICENSE
TX1067786OtherNCCPA