Healthcare Provider Details

I. General information

NPI: 1760419717
Provider Name (Legal Business Name): BLEDSOE TATE OF PRINCETON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/26/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 FULTON AVENUE
BIRMINGHAM AL
35211
US

IV. Provider business mailing address

7088 UNIVERSITY CT
MONTGOMERY AL
36117-6992
US

V. Phone/Fax

Practice location:
  • Phone: 205-780-6333
  • Fax: 205-780-6008
Mailing address:
  • Phone: 334-396-1400
  • Fax: 334-396-2727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DEBRA RICHARDS
Title or Position: PROVIDER RELATIONS COORDINATOR
Credential:
Phone: 334-396-1400