Provider Demographics
NPI:1962779645
Name:THE FATIGUE CLINIC LLC
Entity type:Organization
Organization Name:THE FATIGUE CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:D
Authorized Official - Last Name:EARL
Authorized Official - Suffix:
Authorized Official - Credentials:ACNP
Authorized Official - Phone:901-221-8621
Mailing Address - Street 1:890 W POPLAR AVE STE 6
Mailing Address - Street 2:
Mailing Address - City:COLLIERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38017-2582
Mailing Address - Country:US
Mailing Address - Phone:901-221-8621
Mailing Address - Fax:901-221-8631
Practice Address - Street 1:890 W POPLAR AVE STE 6
Practice Address - Street 2:
Practice Address - City:COLLIERVILLE
Practice Address - State:TN
Practice Address - Zip Code:38017-2582
Practice Address - Country:US
Practice Address - Phone:901-221-8621
Practice Address - Fax:901-221-8631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-22
Last Update Date:2020-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12687261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center