1376851162 NPI number — STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH

Table of content: (NPI 1376851162)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376851162 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:
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:
1376851162
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/15/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
15 HOSPITAL RD.
Provider Second Line Business Mailing Address:
CRENSHAW CO. HEALTH DEPT
Provider Business Mailing Address City Name:
LUVERNE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36049
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-335-2471
Provider Business Mailing Address Fax Number:
334-335-3795

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
15 HOSPITAL RD.
Provider Second Line Business Practice Location Address:
CRENSHAW CO. HEALTH DEPT
Provider Business Practice Location Address City Name:
LUVERNE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36049
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-335-2471
Provider Business Practice Location Address Fax Number:
334-335-3795
Provider Enumeration Date:
09/15/2010

Additional Information

Authorized Official

Authorized Official Last Name:
TATOM
Authorized Official First Name:
DAJUNA
Authorized Official Middle Name:
LYNN
Authorized Official Title or Position:
NURSE PRACTITIONER
Authorized Official Telephone Number:
334-335-2471

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  1-059257 , 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)





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