1902280126 NPI number — EAST ALABAMA CENTER FOR CHANGE, LLC

Table of content: (NPI 1902280126)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902280126 NPI number — EAST ALABAMA CENTER FOR CHANGE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAST ALABAMA CENTER FOR CHANGE, 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:
1902280126
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/17/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
124 BRAGG AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36830-3809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-734-2603
Provider Business Mailing Address Fax Number:
334-887-0031

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
124 BRAGG AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36830-3809
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-734-2603
Provider Business Practice Location Address Fax Number:
334-887-0031
Provider Enumeration Date:
07/17/2015

Additional Information

Authorized Official

Authorized Official Last Name:
DOUGLAS
Authorized Official First Name:
AMBER
Authorized Official Middle Name:
ELIZABETH
Authorized Official Title or Position:
LICENSED PSYCHOLOGIST
Authorized Official Telephone Number:
334-734-2603

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  AL1749 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 103TH0004X , with the licence number: AL1749 , registered in the state of AL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 102I626774 . This is a "MEDICARE PTAN" identifier , issued by the state of ( AL ) . This identifiers is of the category "OTHER".




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