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General NPI Number Information
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NPI Number | 1033604574
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Entity Type | Organization
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Legal Business Name | CLINIC LLC
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Dates
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Enumeration Date | 06/27/2018
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Last Update Date | 04/25/2019
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Provider Practice Location Address
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Address Line | 3393 KIRBY RD
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City | MEMPHIS
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State | TN
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Zip | 38115-4253
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Country | US
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Telephone | 901-542-0864
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Fax |
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Provider Business Mailing Address
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Address Line | 1011 W POPLAR AVE STE 5
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City | COLLIERVILLE
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State | TN
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Zip | 38017-2577
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Country | US
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Telephone | 901-607-9064
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DAVID CONNER
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Credential | MD
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Telephone | 901-270-9145
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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