Basic Information
| Provider Information | |||||||||
| NPI: | 1194903997 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PROFESSIONAL RESOURCES MANAGEMENT, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | PERFECT KIDS AND FAMILY CARE CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 5013 | ||||||||
| Address2: | |||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361035013 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343860343 | ||||||||
| FaxNumber: | 3343860382 | ||||||||
| Practice Location | |||||||||
| Address1: | 308 PRAIRIE ST N | ||||||||
| Address2: | |||||||||
| City: | UNION SPRINGS | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360891417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347381500 | ||||||||
| FaxNumber: | 3347381478 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/04/2008 | ||||||||
| LastUpdateDate: | 06/07/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | LAWRENSON | ||||||||
| AuthorizedOfficialFirstName: | VICKI | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | COO | ||||||||
| AuthorizedOfficialTelephone: | 3343860343 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | PROFESSIONAL RESOURCES MANAGEMENT, INC. | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208000000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Pediatrics | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 051050994 | 01 | AL | BLUE CROSS | OTHER | 540003433 | 05 | AL | MEDICAID |