Basic Information
| Provider Information | |||||||||
| NPI: | 1871847418 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PICKENS COUNTY HEALTH CARE AUTHORITY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | MEDICAL CENTER HOME HEALTH | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | P.O. BOX 147 | ||||||||
| Address2: | 241 ROBERT K. WILSON DRIVE | ||||||||
| City: | CARROLLTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053678111 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 241 ROBERT K. WILSON DRIVE | ||||||||
| Address2: | |||||||||
| City: | CARROLLTON | ||||||||
| State: | AL | ||||||||
| PostalCode: | 35447 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2053678111 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2012 | ||||||||
| LastUpdateDate: | 08/13/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HAMLIN | ||||||||
| AuthorizedOfficialFirstName: | SHARON | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT ADMINISTRATOR OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 2053672442 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | R.N. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | MED7092A | 05 | AL | MEDICAID |