1790383792 NPI number — DESTINEE ELIZABETH BRAGWELL PT, DPT

Table of content: DESTINEE ELIZABETH BRAGWELL PT, DPT (NPI 1790383792)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790383792 NPI number — DESTINEE ELIZABETH BRAGWELL PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
BRAGWELL
Provider First Name:
DESTINEE
Provider Middle Name:
ELIZABETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

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:
1790383792
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/11/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1200 CORPORATE DR STE 400
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HOOVER
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35242-5424
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-238-7217
Provider Business Mailing Address Fax Number:
423-238-3473

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2555 HIGHWAY 78 E
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JASPER
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35501-3433
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-385-7919
Provider Business Practice Location Address Fax Number:
205-803-6458
Provider Enumeration Date:
10/12/2020

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  PTH10102 , 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)





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