Basic Information
| Provider Information | |||||||||
| NPI: | 1972608941 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EASTER SEALS ALABAMA, INC. EASTER SEALS WEST ALABAMA | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | EASTER SEALS WEST ALABAMA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 2817 | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354032817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057591211 | ||||||||
| FaxNumber: | 2053491162 | ||||||||
| Practice Location | |||||||||
| Address1: | 1110 DR. EDWARD HILLARD DRIVE | ||||||||
| Address2: | |||||||||
| City: | TUSCALOOSA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 354013207 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2057591211 | ||||||||
| FaxNumber: | 2053491162 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/14/2006 | ||||||||
| LastUpdateDate: | 07/21/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JOHNSTON | ||||||||
| AuthorizedOfficialFirstName: | RONNY | ||||||||
| AuthorizedOfficialMiddleName: | B. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2057591211 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0400X | 12008 | AL | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation |
ID Information
| ID | Type | State | Issuer | Description | 515-31066 | 01 | AL | BLUE CROSS & BLUE SHIELD | OTHER | 51531482 | 01 | AL | BLUE CROSS & BLUE SHIELD | OTHER | 010-175 | 01 | AL | BLUE CROSS & BLUE SHIELD | OTHER | 529101420 | 05 | AL | MEDICAID | 010-175 | 01 | AL | BCBS OF ALABAMA | OTHER | 51077985 | 01 | AL | BLUE CROSS & BLUE SHIELD | OTHER | 51515014 | 01 | AL | BLUE CROSS & BLUE SHIELD | OTHER | 51533901 | 01 | AL | BLUE CROSS & BLUE SHIELD | OTHER |