1720069628 NPI number — CHOICE SOURCE THERAPEUTIC SOUTH LLC

Table of content: (NPI 1720069628)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1720069628 NPI number — CHOICE SOURCE THERAPEUTIC SOUTH LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHOICE SOURCE THERAPEUTIC SOUTH 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:
1720069628
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/20/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
DEPARTMENT 6175
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90088-6175
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
800-225-5967
Provider Business Mailing Address Fax Number:
909-799-4364

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1048 STANTON RD
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
DAPHNE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36526-4294
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
251-621-5300
Provider Business Practice Location Address Fax Number:
251-621-5318
Provider Enumeration Date:
11/08/2005

Additional Information

Authorized Official

Authorized Official Last Name:
BORDER
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
WILLIAM
Authorized Official Title or Position:
AUTHORIZED SIGNER
Authorized Official Telephone Number:
800-225-5967

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X , with the licence number:  112079 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 333600000X , with the licence number: 112079 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3336S0011X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0330543 , issued by the state of ( MS ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com