Healthcare Provider Details

I. General information

NPI: 1942469606
Provider Name (Legal Business Name): THE CHILDREN'S CLINIC OF WEST TENNESSEE P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2008
Last Update Date: 06/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 COATSLAND DR
JACKSON TN
38301-3948
US

IV. Provider business mailing address

264 COATSLAND DR
JACKSON TN
38301-3948
US

V. Phone/Fax

Practice location:
  • Phone: 731-423-1500
  • Fax: 731-423-0342
Mailing address:
  • Phone: 731-423-1500
  • Fax: 731-423-0342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID LESLIE SELF JR.
Title or Position: PARTNER
Credential: M.D.
Phone: 731-423-1500