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General NPI Number Information
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NPI Number | 1417093857
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Entity Type | Organization
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Legal Business Name | WYNN HABERSHAM COMMUNITY CLINIC INC
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Dates
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Enumeration Date | 01/30/2007
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Last Update Date | 07/16/2007
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Provider Practice Location Address
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Address Line | 1037 STINKING CREEK RD
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City | LA FOLLETTE
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State | TN
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Zip | 37766-6108
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Country | US
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Telephone | 423-784-5110
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 946
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City | JELLICO
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State | TN
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Zip | 37762-0946
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Country | US
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Telephone | 423-784-0269
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DR. CHARLES H. WILKENS
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Credential | M.D.
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Telephone | 423-784-5110
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QR1300X
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Taxonomy Name | Rural Health Clinic/Center
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License Number |
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License Number State |
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