Healthcare Provider Details

I. General information

NPI: 1164674818
Provider Name (Legal Business Name): WAWA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/14/2008
Last Update Date: 10/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4126 NOLENSVILLE RD
NASHVILLE TN
37211-4717
US

IV. Provider business mailing address

4126 NOLENSVILLE RD
NASHVILLE TN
37211-4717
US

V. Phone/Fax

Practice location:
  • Phone: 615-834-2170
  • Fax: 615-833-6995
Mailing address:
  • Phone: 615-834-2170
  • Fax: 615-833-6995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number27619
License Number StateTN

VIII. Authorized Official

Name: DR. FRITZ WAWA
Title or Position: OWNER
Credential: MD
Phone: 615-834-2170