Provider Demographics
NPI:1841696879
Name:TIFTON CLINIC LLC
Entity type:Organization
Organization Name:TIFTON CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:WENDELL
Authorized Official - Middle Name:L
Authorized Official - Last Name:SIMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:229-890-3531
Mailing Address - Street 1:PO BOX 2876
Mailing Address - Street 2:
Mailing Address - City:MOULTRIE
Mailing Address - State:GA
Mailing Address - Zip Code:31776-2876
Mailing Address - Country:US
Mailing Address - Phone:229-891-9131
Mailing Address - Fax:
Practice Address - Street 1:1623 OLD OCILLA RD
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-4173
Practice Address - Country:US
Practice Address - Phone:229-891-9131
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COLQUITT REGIONAL MEDICAL INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-11-19
Last Update Date:2014-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty