=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457401416
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WEST CLINIC PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 11/10/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6025 WALNUT GROVE RD STE. 111
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38120-2102
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-818-0300
-----------------------------------------------------
Fax | 901-818-0458
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 100 N HUMPHREYS BLVD
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38120-2146
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-683-0055
-----------------------------------------------------
Fax | 901-322-9097
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. RONALD O DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-683-0055
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------