Basic Information
| Provider Information | |||||||||
| NPI: | 1518051267 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HOUSTON COUNTY HEALTHCARE AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | WOMEN'S BOUTIQUE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1108 ROSS CLARK CIR | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363013022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938111 | ||||||||
| FaxNumber: | 3347938191 | ||||||||
| Practice Location | |||||||||
| Address1: | 1108 ROSS CLARK CIR | ||||||||
| Address2: | |||||||||
| City: | DOTHAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 363013022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3347938111 | ||||||||
| FaxNumber: | 3347938191 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 11/05/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COCHRAN | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | BILLING MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3347123311 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPC | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 51518564 | 01 | AL | BCBS OF ALABAMA | OTHER |