1255409447 NPI number — SELF-RECOVERY, LLC

Table of content: (NPI 1255409447)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1255409447 NPI number — SELF-RECOVERY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SELF-RECOVERY, 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:
1255409447
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
106 N LANIER AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LANETT
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36863-2014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-644-6848
Provider Business Mailing Address Fax Number:
334-644-5543

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
106 N LANIER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LANETT
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36863-2014
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-644-6848
Provider Business Practice Location Address Fax Number:
334-644-5443
Provider Enumeration Date:
12/04/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MOORE
Authorized Official First Name:
TOMMY
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
334-644-6848

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , with the licence number:  00022660 , 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)

  • Identifier: 51529504 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".
  • Identifier: 051555920 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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