Basic Information
| Provider Information | |||||||||
| NPI: | 1790810950 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMPLETE FAMILY PRACTICE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ASC OCCUPATIONAL HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 638 | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350560638 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567379416 | ||||||||
| FaxNumber: | 2567365684 | ||||||||
| Practice Location | |||||||||
| Address1: | 1908 CHEROKEE AVE SW | ||||||||
| Address2: | |||||||||
| City: | CULLMAN | ||||||||
| State: | AL | ||||||||
| PostalCode: | 350555502 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2567361460 | ||||||||
| FaxNumber: | 2567361458 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2007 | ||||||||
| LastUpdateDate: | 07/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | WATKINS | ||||||||
| AuthorizedOfficialFirstName: | LAGEITA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 2567379416 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2083P0500X | 00018184 | AL | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Preventive Medicine | Preventive Medicine/Occupational Environmental Medicine |
ID Information
| ID | Type | State | Issuer | Description | 1629093638 | 01 | NPI | OTHER | 1235175886 | 01 | NPI | OTHER |