1104572254 NPI number — INDEPENDENT LIVING CENTER OF BIRMINGHAM

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 1104572254 NPI number — INDEPENDENT LIVING CENTER OF BIRMINGHAM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENT LIVING CENTER OF BIRMINGHAM
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:
1104572254
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/28/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 1805
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:
35201-1805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-815-6142
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1418 6TH AVE N
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:
35203-1804
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-815-6142
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/28/2022

Additional Information

Authorized Official

Authorized Official Last Name:
STANLEY
Authorized Official First Name:
CHRISTIE
Authorized Official Middle Name:
Authorized Official Title or Position:
PROGRAM COORDINATOR
Authorized Official Telephone Number:
205-815-6142

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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