MEDICARE: COMMUNITY CARE CLINIC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	F0906005	TN

General Provider Information

NPI Number	:	1699946103
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	COMMUNITY CARE CLINIC LLC

Provider Business Mailing Address
First Line	:	PO BOX 306
Second Line	:
City	:	OCOEE
State	:	TN
Zip	:	37361-0306
Country	:	US
Telephone Number	:	423-338-7434
Fax Number	:	423-338-7436

Provider Business Practice Location Address
First Line	:	4867 HIGHWAY 411
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37323-5360
Country	:	US
Telephone Number	:	423-338-7434
Fax Number	:	423-338-7436

Authorized Official
Title or Position	:	PRACTICIONER/OWNER
Name	:	WENDY L BECK
Credential	:	NP-C
Telephone Number	:	423-338-7434

Provider Enumeration Date	:	03/13/2008
Last Update Date	:	03/13/2008

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