Basic Information
Provider Information | |||||||||
NPI: | 1275707028 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PRIVATE DUTY NURSING SERVICES, INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 317 W STATE ST | ||||||||
Address2: |   | ||||||||
City: | MUSCLE SHOALS | ||||||||
State: | AL | ||||||||
PostalCode: | 356612835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563551811 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 317 W STATE ST | ||||||||
Address2: |   | ||||||||
City: | MUSCLE SHOALS | ||||||||
State: | AL | ||||||||
PostalCode: | 356612835 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2563551811 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/14/2008 | ||||||||
LastUpdateDate: | 04/14/2008 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STANDRIDGE | ||||||||
AuthorizedOfficialFirstName: | SHERRY | ||||||||
AuthorizedOfficialMiddleName: | A | ||||||||
AuthorizedOfficialTitleorPosition: | ACCOUNTING MANAGER | ||||||||
AuthorizedOfficialTelephone: | 2563551811 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 04825 | AL | Y |   | Agencies | Home Health |   |
ID Information
ID | Type | State | Issuer | Description | PVT0069Z | 05 | AL |   | MEDICAID |