Provider Demographics
NPI:1699946103
Name:COMMUNITY CARE CLINIC LLC
Entity type:Organization
Organization Name:COMMUNITY CARE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICIONER/OWNER
Authorized Official - Prefix:
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:L
Authorized Official - Last Name:BECK
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:423-338-7434
Mailing Address - Street 1:PO BOX 306
Mailing Address - Street 2:
Mailing Address - City:OCOEE
Mailing Address - State:TN
Mailing Address - Zip Code:37361-0306
Mailing Address - Country:US
Mailing Address - Phone:423-338-7434
Mailing Address - Fax:423-338-7436
Practice Address - Street 1:4867 HIGHWAY 411
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37323-5360
Practice Address - Country:US
Practice Address - Phone:423-338-7434
Practice Address - Fax:423-338-7436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-13
Last Update Date:2008-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNF0906005207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNA55059Medicare UPIN