Healthcare Provider Details

I. General information

NPI: 1407339328
Provider Name (Legal Business Name): PRICEVILLE PRIMARY CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2018
Last Update Date: 10/24/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

68 MARCO DR
DECATUR AL
35603-5425
US

IV. Provider business mailing address

1201 7TH ST SE
DECATUR AL
35601-3337
US

V. Phone/Fax

Practice location:
  • Phone: 256-973-2802
  • Fax: 256-686-0178
Mailing address:
  • Phone: 256-973-2802
  • Fax: 256-973-2552

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberRN1-151783
License Number StateAL

VIII. Authorized Official

Name: KELLI S POWERS
Title or Position: CEO
Credential:
Phone: 256-973-3535