MEDICARE: WM CLARK ALZ CARE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA0600X	Adult Day Care Clinic/Center

General Provider Information

NPI Number	:	1215478714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WM CLARK ALZ CARE

Provider Business Mailing Address
First Line	:	3150 WOODLAND FIR DR
Second Line	:
City	:	LAKELAND
State	:	TN
Zip	:	38002-3957
Country	:	US
Telephone Number	:	901-267-4002
Fax Number	:

Provider Business Practice Location Address
First Line	:	6222 EAST SHEBY DRIVE
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38141-7735
Country	:	US
Telephone Number	:	901-267-4002
Fax Number	:

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	ROMINIC CLARK
Credential	:
Telephone Number	:	901-267-4002

Provider Enumeration Date	:	03/16/2017
Last Update Date	:	03/29/2017

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