1265705065 NPI number — CLOVERDALE ROAD FAMILY MEDICAL CENTER

Table of content: (NPI 1265705065)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265705065 NPI number — CLOVERDALE ROAD FAMILY MEDICAL CENTER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CLOVERDALE ROAD FAMILY MEDICAL CENTER
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:
1265705065
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/10/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 895
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SHEFFIELD
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35660-0895
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-764-1263
Provider Business Mailing Address Fax Number:
256-764-9611

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3502 CLOVERDALE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FLORENCE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35633-1302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
256-764-1263
Provider Business Practice Location Address Fax Number:
256-764-9611
Provider Enumeration Date:
02/10/2012

Additional Information

Authorized Official

Authorized Official Last Name:
LEONARD
Authorized Official First Name:
CAROLYN
Authorized Official Middle Name:
Authorized Official Title or Position:
CONTROLLER
Authorized Official Telephone Number:
256-386-4673

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  8871 , 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)





Copyright © 2007-2025 www.npivalidator.com