=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124410410
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CLINTON WELLNESS CENTER LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/24/2015
-----------------------------------------------------
Last Update Date | 02/24/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 322 HIGHWAY 80 E SUITE D
-----------------------------------------------------
City | CLINTON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39056-4726
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-791-3765
-----------------------------------------------------
Fax | 877-747-5326
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 59294
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MS
-----------------------------------------------------
Zip | 39284-9294
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 318-791-3765
-----------------------------------------------------
Fax | 877-747-5326
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. MARCO MORAN
-----------------------------------------------------
Credential | DPH
-----------------------------------------------------
Telephone | 318-791-3765
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------