1710938998 NPI number — SHELBY RIDGE ACQUISITION CORPORATION

Table of content: (NPI 1710938998)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710938998 NPI number — SHELBY RIDGE ACQUISITION CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SHELBY RIDGE ACQUISITION CORPORATION
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:
SHELBY RIDGE NURSING HOME
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:
1710938998
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/11/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
881 3RD ST NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ALABASTER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35007-8954
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-620-8500
Provider Business Mailing Address Fax Number:
205-620-8553

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
881 3RD ST NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ALABASTER
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35007-8954
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-620-8500
Provider Business Practice Location Address Fax Number:
205-620-8553
Provider Enumeration Date:
05/13/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STEPHENSON
Authorized Official First Name:
TAMMY
Authorized Official Middle Name:
MOCK
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
334-273-9002

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  12676 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 009936913 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 47-58040S , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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