MEDICARE: JACQUELINE CHILDS OTRL

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist	1913	AL

General Provider Information

NPI Number	:	1396964383
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE CHILDS OTRL

Provider Business Mailing Address
First Line	:	802 HAND AVE
Second Line	:
City	:	BAY MINETTE
State	:	AL
Zip	:	36507-4511
Country	:	US
Telephone Number	:	251-580-8064
Fax Number	:	251-580-8239

Provider Business Practice Location Address
First Line	:	107 N HOYLE AVE
Second Line	:
City	:	BAY MINETTE
State	:	AL
Zip	:	36507-4827
Country	:	US
Telephone Number	:	251-580-8236
Fax Number	:	251-580-8239

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/25/2007
Last Update Date	:	07/08/2007

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Directions to “ JACQUELINE CHILDS OTRL” Practice Location

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