Healthcare Provider Details

I. General information

NPI: 1578891115
Provider Name (Legal Business Name): SONTHE BOKAS BURGE MS RD LD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2009
Last Update Date: 11/19/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1310 ALFORD AVE SUITE 201
BIRMINGHAM AL
35226-3199
US

IV. Provider business mailing address

1310 ALFORD AVE SUITE 201
BIRMINGHAM AL
35226-3199
US

V. Phone/Fax

Practice location:
  • Phone: 205-979-6822
  • Fax: 205-979-6246
Mailing address:
  • Phone: 205-979-6822
  • Fax: 205-979-6246

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number1830
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: