Organization
CLINTON WELLNESS CENTER LLC
Active
Other names
ICare
Organization subpart
No
Provider details
NPI number
Authorized official
DR. SHINITA REED DUDLEY M.D (PHYSICIAN)
(601) 714-8180
Entity
Organization
Contact information
Practice address
514 E WOODROW WILSON AVE, SUITE C, JACKSON, MS 39216-4538
(601) 714-8180
(601) 922-9900
Mailing address
514 E WOODROW WILSON AVE, SUITE C, JACKSON, MS 39216-4538
(601) 714-8180
(601) 922-9900
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
Primary
18239
MS
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
07033864
—
MS
01
—
1413306
BCBS OF TENN
TN
01
—
512I080023
MISSISSIPPI MEDICARE NUMBER
MS
01
—
587159423I
BCBS
MS
Enumeration date
11/01/2012
Last updated
11/01/2012
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