1639117633 NPI number — MORNINGSIDE OF FAYETTE, L.P.

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 1639117633 NPI number — MORNINGSIDE OF FAYETTE, L.P.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MORNINGSIDE OF FAYETTE, L.P.
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:
MORNINGSIDE OF FAYETTE
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:
1639117633
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/27/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
400 CENTRE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEWTON
Provider Business Mailing Address State Name:
MA
Provider Business Mailing Address Postal Code:
02458-2094
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
617-796-8387
Provider Business Mailing Address Fax Number:
617-796-8385

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 25TH ST NW
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FAYETTE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35555-1129
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-932-4003
Provider Business Practice Location Address Fax Number:
205-932-8636
Provider Enumeration Date:
06/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MACKEY
Authorized Official First Name:
BRUCE
Authorized Official Middle Name:
J
Authorized Official Title or Position:
PRESIDENT & CHIEF EXECUTIVE OFFICER
Authorized Official Telephone Number:
617-796-8214

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  11204 , 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)