Provider Demographics
NPI:1952134512
Name:EN BONNE SANTE CLINIC LLC
Entity type:Organization
Organization Name:EN BONNE SANTE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:JEANINE
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:239-443-8018
Mailing Address - Street 1:17 HAMPTON ST STE F
Mailing Address - Street 2:
Mailing Address - City:MCDONOUGH
Mailing Address - State:GA
Mailing Address - Zip Code:30253-3159
Mailing Address - Country:US
Mailing Address - Phone:239-443-8018
Mailing Address - Fax:
Practice Address - Street 1:17 HAMPTON ST STE F
Practice Address - Street 2:
Practice Address - City:MCDONOUGH
Practice Address - State:GA
Practice Address - Zip Code:30253-3159
Practice Address - Country:US
Practice Address - Phone:239-443-8018
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-20
Last Update Date:2024-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health