=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407389356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WM CLARK ALZ CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2017
-----------------------------------------------------
Last Update Date | 04/07/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 672 ALABAMA AVE
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38105-3702
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-267-4002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3150 WOODLAND FIR DR
-----------------------------------------------------
City | LAKELAND
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38002-3957
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-267-4002
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | ROMINIC CLARK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-267-4002
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------