Provider Demographics
NPI:1538435375
Name:WILLISTON RURAL HEALTH AND WELLNESS CLINIC LLC
Entity type:Organization
Organization Name:WILLISTON RURAL HEALTH AND WELLNESS CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SIDNEY
Authorized Official - Middle Name:ERNEST
Authorized Official - Last Name:CLEVINGER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-266-7075
Mailing Address - Street 1:300 NW 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:WILLISTON
Mailing Address - State:FL
Mailing Address - Zip Code:32696-2006
Mailing Address - Country:US
Mailing Address - Phone:352-529-0966
Mailing Address - Fax:352-529-0967
Practice Address - Street 1:300 NW 1ST AVE
Practice Address - Street 2:
Practice Address - City:WILLISTON
Practice Address - State:FL
Practice Address - Zip Code:32696-2006
Practice Address - Country:US
Practice Address - Phone:352-529-0966
Practice Address - Fax:352-529-0967
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-27
Last Update Date:2013-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health