Healthcare Provider Details

I. General information

NPI: 1487104998
Provider Name (Legal Business Name): SOUTHERN ALABAMA REGIONAL COUNCIL ON AGING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/07/2016
Last Update Date: 04/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S BRANNON STAND RD
DOTHAN AL
36305-7359
US

IV. Provider business mailing address

1075 S BRANNON STAND RD
DOTHAN AL
36305-7359
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-6843
  • Fax:
Mailing address:
  • Phone: 334-793-6843
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number1-054943
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: DANA EIDSON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 334-793-6843