Healthcare Provider Details

I. General information

NPI: 1578626669
Provider Name (Legal Business Name): MIDSOUTH A GENTIVA COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

631 BEACON PKWY W
BIRMINGHAM AL
35209-3124
US

IV. Provider business mailing address

631 BEACON PKWY W
BIRMINGHAM AL
35209-3124
US

V. Phone/Fax

Practice location:
  • Phone: 205-945-4859
  • Fax: 205-945-8605
Mailing address:
  • Phone: 205-945-4859
  • Fax: 205-945-8605

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberPTH1397
License Number StateAL

VIII. Authorized Official

Name: BRENDA LONG CHAPPELL
Title or Position: PHYSICAL THERAPIST
Credential:
Phone: 205-945-4859