1326184029 NPI number — PRATTVILLE PRIMARY CARE LLC

Table of content: (NPI 1326184029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1326184029 NPI number — PRATTVILLE PRIMARY CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PRATTVILLE PRIMARY CARE 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:
1326184029
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/21/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO DRAWER 681330
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PRATTVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36068-1330
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-365-2205
Provider Business Mailing Address Fax Number:
334-361-7975

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
461 E MAIN STREET
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PRATTVILLE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36067
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-365-2205
Provider Business Practice Location Address Fax Number:
334-361-7975
Provider Enumeration Date:
01/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
INGRAM
Authorized Official First Name:
DANNY
Authorized Official Middle Name:
P
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
334-365-2205

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  10401 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 000030008 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 51030008 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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