1174603740 NPI number — STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174603740 NPI number — STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CULLMAN COUNTY HOME CARE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174603740
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
201 MONROE ST
Provider Second Line Business Mailing Address:
THE RSA TOWER, SUITE 1200
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36104-3735
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-206-5341
Provider Business Mailing Address Fax Number:
334-206-5724

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
601 LOGAN AVE SW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CULLMAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35055-4520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-734-0258
Provider Business Practice Location Address Fax Number:
256-734-1840
Provider Enumeration Date:
10/17/2006

Additional Information

Authorized Official

Authorized Official Last Name:
WEDGEWORTH
Authorized Official First Name:
GROVER
Authorized Official Middle Name:
T
Authorized Official Title or Position:
STATE HOME CARE DIRECTOR
Authorized Official Telephone Number:
334-206-5341

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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