Healthcare Provider Details

I. General information

NPI: 1164794343
Provider Name (Legal Business Name): GMUC OF CITRONELLE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/02/2012
Last Update Date: 08/02/2023
Certification Date: 08/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19355 N 3RD ST SUITE 104
CITRONELLE AL
36522-2049
US

IV. Provider business mailing address

7943 MOFFETT RD
SEMMES AL
36575-5409
US

V. Phone/Fax

Practice location:
  • Phone: 251-633-0123
  • Fax: 251-445-3722
Mailing address:
  • Phone: 251-633-0123
  • Fax: 251-445-3722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DARREN K WATERS
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 251-633-0123