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General NPI Number Information
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NPI Number | 1710231576
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Entity Type | Organization
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Legal Business Name | CLINTON WELLNESS CENTER LLC
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Dates
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Enumeration Date | 11/01/2012
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Last Update Date | 11/01/2012
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Provider Practice Location Address
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Address Line | 514 E WOODROW WILSON AVE SUITE C
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City | JACKSON
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State | MS
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Zip | 39216-4538
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Country | US
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Telephone | 601-714-8180
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Fax | 601-922-9900
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Provider Business Mailing Address
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Address Line | 514 E WOODROW WILSON AVE SUITE C
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City | JACKSON
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State | MS
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Zip | 39216-4538
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Country | US
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Telephone | 601-714-8180
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Fax | 601-922-9900
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Authorized Official
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Title or Position | PHYSICIAN
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Name | DR. SHINITA REED DUDLEY
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Credential | M.D
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Telephone | 601-714-8180
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 18239
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License Number State | MS
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