Healthcare Provider Details

I. General information

NPI: 1083192173
Provider Name (Legal Business Name): SHOALS INFECTIOUS DISEASE CONSULTANTS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/01/2018
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22281 US HIGHWAY 72 STE A
ATHENS AL
35613-2601
US

IV. Provider business mailing address

PO BOX 1077
FLORENCE AL
35630
US

V. Phone/Fax

Practice location:
  • Phone: 256-444-4401
  • Fax: 256-444-4403
Mailing address:
  • Phone: 256-444-4401
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number180531025
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMD.36985
License Number State
# 3
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License NumberMD.36985
License Number State

VIII. Authorized Official

Name: JEAN HILAIRE VINCENT
Title or Position: OWNER
Credential: MD
Phone: 256-444-4401