1417317488 NPI number — PROFESSIONAL MED-HEALTH LLC

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 1417317488 NPI number — PROFESSIONAL MED-HEALTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PROFESSIONAL MED-HEALTH 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:
1417317488
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/03/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1157 INVERNESS COVE WAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BIRMINGHAM
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35242
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
251-298-0917
Provider Business Mailing Address Fax Number:
205-747-0133

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1157 INVERNESS COVE WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIRMINGHAM
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35242-4258
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-298-0917
Provider Business Practice Location Address Fax Number:
205-747-0133
Provider Enumeration Date:
03/03/2016

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
DAVIS
Authorized Official First Name:
MIRANDA
Authorized Official Middle Name:
Authorized Official Title or Position:
CLINICAL MANAGER/OWNER
Authorized Official Telephone Number:
251-298-0917

Provider Taxonomy Codes

  • Taxonomy code: 253Z00000X , 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)