Basic Information
Provider Information | |||||||||
NPI: | 1972981918 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | TBD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 76359 AL HIGHWAY 77 | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | AL | ||||||||
PostalCode: | 35096 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2052593991 | ||||||||
FaxNumber: | 2056832468 | ||||||||
Practice Location | |||||||||
Address1: | 76359 AL HIGHWAY 77 | ||||||||
Address2: |   | ||||||||
City: | LINCOLN | ||||||||
State: | AL | ||||||||
PostalCode: | 350965039 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2052593991 | ||||||||
FaxNumber: | 2056832468 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/11/2015 | ||||||||
LastUpdateDate: | 10/26/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | STACY | ||||||||
AuthorizedOfficialFirstName: | BRET | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | PHYSICAL THERAPIST | ||||||||
AuthorizedOfficialTelephone: | 2052593991 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PT | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | PTH7544 | AL | Y | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |   |
No ID Information.