Provider Demographics
NPI:1215532759
Name:WILD HEALTH URI CLINIC, LLC
Entity type:Organization
Organization Name:WILD HEALTH URI CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL ADMINISTRATIVE OFFICE
Authorized Official - Prefix:MR
Authorized Official - First Name:PHILLIP
Authorized Official - Middle Name:ANDREW
Authorized Official - Last Name:WILLIFORD
Authorized Official - Suffix:
Authorized Official - Credentials:MSPAS, PA-C
Authorized Official - Phone:859-439-0400
Mailing Address - Street 1:535 WELLINGTON WAY STE 330
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-1331
Mailing Address - Country:US
Mailing Address - Phone:859-439-0400
Mailing Address - Fax:859-439-0399
Practice Address - Street 1:881 CORPORATE DR
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-2748
Practice Address - Country:US
Practice Address - Phone:859-757-1949
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-02
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty