1962526301 NPI number — WELLSPRING CHRISTIAN CLINIC, 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 1962526301 NPI number — WELLSPRING CHRISTIAN CLINIC, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLSPRING CHRISTIAN CLINIC, 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:
1962526301
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/06/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3104 BLUE LAKE DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
VESTAVIA
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
35243-2345
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
205-977-3003
Provider Business Mailing Address Fax Number:
205-977-3939

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3104 BLUE LAKE DR
Provider Second Line Business Practice Location Address:
SUITE 100
Provider Business Practice Location Address City Name:
VESTAVIA
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
35243-2345
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
205-977-3003
Provider Business Practice Location Address Fax Number:
205-977-3939
Provider Enumeration Date:
03/19/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SAUNDERS
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
AL
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
205-977-3003

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X , with the licence number:  889 , 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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