Healthcare Provider Details

I. General information

NPI: 1841696879
Provider Name (Legal Business Name): TIFTON CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/19/2014
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1623 OLD OCILLA RD
TIFTON GA
31794-4173
US

IV. Provider business mailing address

PO BOX 2876
MOULTRIE GA
31776-2876
US

V. Phone/Fax

Practice location:
  • Phone: 229-891-9131
  • Fax:
Mailing address:
  • Phone: 229-891-9131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: WENDELL L SIMS
Title or Position: COO
Credential:
Phone: 229-890-3531