1609457662 NPI number — TRACY D ADAMS

Table of content: (NPI 1609457662)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1609457662 NPI number — TRACY D ADAMS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
TRACY D ADAMS
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:
1609457662
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2905 BOB WALLACE AVE SE SUITE B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HUNTSVILLE
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35805
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
256-203-2647
Provider Business Mailing Address Fax Number:
256-964-8134

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1290 1ST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAWRENCEBURG
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38464-2762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-244-7558
Provider Business Practice Location Address Fax Number:
931-244-7560
Provider Enumeration Date:
04/20/2021

Additional Information

Authorized Official

Authorized Official Last Name:
ADAMS
Authorized Official First Name:
TRACY
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
931-244-7558

Provider Taxonomy Codes

  • Taxonomy code: 335E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 14408701 . This is a "CAQH" identifier . This identifiers is of the category "OTHER".
  • Identifier: 228420 , issued by the state of ( AL ) . This identifiers is of the category "MEDICAID".




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