Basic Information
| Provider Information | |||||||||
| NPI: | 1134357122 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WEST CLINIC, PC | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 100 N HUMPHREYS BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381202146 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016830055 | ||||||||
| FaxNumber: | 9013222994 | ||||||||
| Practice Location | |||||||||
| Address1: | 201 LAKEVIEW RD | ||||||||
| Address2: | SUITE A | ||||||||
| City: | SOMERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380689742 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9016837936 | ||||||||
| FaxNumber: | 9017866189 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2009 | ||||||||
| LastUpdateDate: | 10/20/2011 | ||||||||
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| AuthorizedOfficialLastName: | DAVIS | ||||||||
| AuthorizedOfficialFirstName: | RONALD | ||||||||
| AuthorizedOfficialMiddleName: | O | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9016830055 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.