1194092478 NPI number — CRENSHAW FAMILY CARE CENTER, LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194092478 NPI number — CRENSHAW FAMILY CARE CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CRENSHAW FAMILY CARE CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194092478
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/07/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 5013
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MONTGOMERY
Provider Business Mailing Address State Name:
AL
Provider Business Mailing Address Postal Code:
36103-5013
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
334-386-0343
Provider Business Mailing Address Fax Number:
334-386-0382

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
58 ROY BEALL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LUVERNE
Provider Business Practice Location Address State Name:
AL
Provider Business Practice Location Address Postal Code:
36049-6800
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
334-335-1212
Provider Business Practice Location Address Fax Number:
334-335-1217
Provider Enumeration Date:
11/30/2011

Additional Information

Authorized Official

Authorized Official Last Name:
LAWRENSON
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
F
Authorized Official Title or Position:
COO
Authorized Official Telephone Number:
334-386-0343

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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