1295166346 NPI number — DOTHAN BEHAVIORAL MEDICINE CLINIC PC

Table of content: (NPI 1295166346)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295166346 NPI number — DOTHAN BEHAVIORAL MEDICINE CLINIC PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DOTHAN BEHAVIORAL MEDICINE CLINIC PC
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:
6
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:
1295166346
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/18/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
408 HEALTHWEST DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DOTHAN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36303-2054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-479-0541
Provider Business Mailing Address Fax Number:
334-479-0586

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
408 HEALTHWEST DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36303-2054
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-479-0541
Provider Business Practice Location Address Fax Number:
334-479-0586
Provider Enumeration Date:
11/27/2013

Additional Information

Authorized Official

Authorized Official Last Name:
DAUGHTRY
Authorized Official First Name:
SUSANNAH
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF PHARMACY
Authorized Official Telephone Number:
334-796-1548

Provider Taxonomy Codes

  • Taxonomy code: 333600000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336C0003X , with the licence number: 114222 , 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: 2143097 . This is a "PK" identifier . This identifiers is of the category "OTHER".
  • Identifier: 154463 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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