Healthcare Provider Details

I. General information

NPI: 1912231895
Provider Name (Legal Business Name): MEDICAL SPA MOKSHA, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2009
Last Update Date: 09/25/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 CAHABA PARK CIR
BIRMINGHAM AL
35242-5087
US

IV. Provider business mailing address

500 CAHABA PARK CIR
BIRMINGHAM AL
35242-5087
US

V. Phone/Fax

Practice location:
  • Phone: 205-980-9393
  • Fax: 205-980-4494
Mailing address:
  • Phone: 205-980-9393
  • Fax: 205-980-4494

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number3370
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number3370
License Number StateAL

VIII. Authorized Official

Name: DR. WILLIAM B NICKELL
Title or Position: MEDICAL DIRECTOR
Credential: M.D.
Phone: 205-980-9393