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General NPI Number Information
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NPI Number | 1366841066
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Entity Type | Organization
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Legal Business Name | WEAVER CLINIC, LLC
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Dates
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Enumeration Date | 08/19/2014
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Last Update Date | 12/01/2014
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Provider Practice Location Address
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Address Line | 124 W COMMERCE ST
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City | HERNANDO
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State | MS
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Zip | 38632-2240
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Country | US
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Telephone | 901-262-0185
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Fax |
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Provider Business Mailing Address
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Address Line | 124 W COMMERCE ST
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City | HERNANDO
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State | MS
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Zip | 38632-2240
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Country | US
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Telephone | 901-262-0185
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Fax |
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Authorized Official
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Title or Position | MEDICAL SUPERVISOR
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Name | BEVERLY POUNDERS WEAVER
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Credential | FNP
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Telephone | 901-262-0185
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number | R629189
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License Number State | MS
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