Healthcare Provider Details

I. General information

NPI: 1386860898
Provider Name (Legal Business Name): WELLNESS CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 02/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5740 GETWELL RD BLDG 4C
SOUTHAVEN MS
38672-6346
US

IV. Provider business mailing address

PO BOX 2024
OLIVE BRANCH MS
38654-2209
US

V. Phone/Fax

Practice location:
  • Phone: 662-892-5000
  • Fax: 662-892-5002
Mailing address:
  • Phone: 662-892-5000
  • Fax: 662-892-5002

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TP0016X
TaxonomyPrescribing (Medical) Psychologist
License NumberMD000025744
License Number StateTN

VIII. Authorized Official

Name: SAVIRA V SIDHU
Title or Position: PRESIDENT
Credential: M.D.
Phone: 662-892-5000