Healthcare Provider Details

I. General information

NPI: 1841495603
Provider Name (Legal Business Name): ABC PEDIATRIC CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2007
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 MAIN AVE SW
CULLMAN AL
35055-7200
US

IV. Provider business mailing address

1900 MAIN AVE SW
CULLMAN AL
35055-7200
US

V. Phone/Fax

Practice location:
  • Phone: 256-734-3759
  • Fax: 256-734-9764
Mailing address:
  • Phone: 256-734-3759
  • Fax: 256-734-9764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code173000000X
TaxonomyLegal Medicine
License Number00023029
License Number StateAL

VIII. Authorized Official

Name: DR. LISA KAREN JOINES
Title or Position: OWNER
Credential: M.D.
Phone: 256-734-3759