Healthcare Provider Details

I. General information

NPI: 1124244967
Provider Name (Legal Business Name): SAMUEL K HUTTO PTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/18/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1480 ROSS CLARK CIR
DOTHAN AL
36301-4752
US

IV. Provider business mailing address

PO BOX 729
DOTHAN AL
36302-0729
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-2663
  • Fax: 334-836-2247
Mailing address:
  • Phone: 334-793-2663
  • Fax: 334-836-2247

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA4594
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: