1164794343 NPI number — GMUC OF CITRONELLE LLC

Table of content: (NPI 1164794343)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164794343 NPI number — GMUC OF CITRONELLE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GMUC OF CITRONELLE LLC
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:
Provider Other Organization Name Type Code:
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:
1164794343
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/02/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
7943 MOFFETT RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SEMMES
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36575-5409
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-633-0123
Provider Business Mailing Address Fax Number:
251-445-3722

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
19355 N 3RD ST
Provider Second Line Business Practice Location Address:
SUITE 104
Provider Business Practice Location Address City Name:
CITRONELLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36522-2049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-633-0123
Provider Business Practice Location Address Fax Number:
251-445-3722
Provider Enumeration Date:
02/02/2012

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
WATERS
Authorized Official First Name:
DARREN
Authorized Official Middle Name:
K
Authorized Official Title or Position:
MEDICAL DIRECTOR
Authorized Official Telephone Number:
251-633-0123

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QU0200X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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