Healthcare Provider Details

I. General information

NPI: 1740611474
Provider Name (Legal Business Name): GILL REYNOLDS-PRIDGETT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2013
Last Update Date: 12/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12 PERIMETER PARK S
BIRMINGHAM AL
35243-2326
US

IV. Provider business mailing address

1320 MAIN ST
COLUMBIA SC
29201-3204
US

V. Phone/Fax

Practice location:
  • Phone: 866-559-5735
  • Fax: 866-558-2242
Mailing address:
  • Phone: 866-559-5735
  • Fax: 866-558-2242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. GILL REYNOLDS-PRIDGETT
Title or Position: EXECUTIVE DIRECTOR
Credential: CEO
Phone: 18665595735