Provider Demographics
NPI:1447508809
Name:CLUBMD, LLC
Entity type:Organization
Organization Name:CLUBMD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:ERIC
Authorized Official - Middle Name:WARREN
Authorized Official - Last Name:BLETZINGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-780-2825
Mailing Address - Street 1:PO BOX 1094
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42102-1094
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1065 ASHLEY ST
Practice Address - Street 2:SUITE 200
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3400
Practice Address - Country:US
Practice Address - Phone:270-467-0010
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CMD HOLDING, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-08-16
Last Update Date:2012-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care