Healthcare Provider Details

I. General information

NPI: 1407937709
Provider Name (Legal Business Name): ANDALUSIA MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/17/2006
Last Update Date: 02/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

670 MOORE RD
ANDALUSIA AL
36420
US

IV. Provider business mailing address

670 MOORE RD
ANDALUSIA AL
36420
US

V. Phone/Fax

Practice location:
  • Phone: 334-222-4544
  • Fax: 334-222-4737
Mailing address:
  • Phone: 334-222-4544
  • Fax: 334-222-4737

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MS. SAL-LEE SHA-REE SASSER
Title or Position: VICE-PRESIDENT
Credential:
Phone: 334-222-4544