1609104736 NPI number — 180 MEDICAL, INC.

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 1609104736 NPI number — 180 MEDICAL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
180 MEDICAL, INC.
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:
1609104736
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/18/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8516 NW EXPRESSWAY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OKLAHOMA CITY
Provider Business Mailing Address State Name:
OK
Provider Business Mailing Address Postal Code:
73162-6010
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-688-2729
Provider Business Mailing Address Fax Number:
888-718-0633

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2830 HORACE SHEPARD DR
Provider Second Line Business Practice Location Address:
SUITE 2
Provider Business Practice Location Address City Name:
DOTHAN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36303-1007
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-803-8135
Provider Business Practice Location Address Fax Number:
888-718-0633
Provider Enumeration Date:
12/01/2009

Additional Information

Authorized Official

Authorized Official Last Name:
HENDRIX
Authorized Official First Name:
JEFFERY
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
405-443-2985

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  946 , 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: 006616600 , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 129293 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".
  • Identifier: 300801390A , issued by the state of ( GA ) . This identifiers is of the category "MEDICAID".
  • Identifier: 006616600 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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