Healthcare Provider Details

I. General information

NPI: 1801830500
Provider Name (Legal Business Name): TRIAD OF ALABAMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2006
Last Update Date: 04/22/2021
Certification Date: 04/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4370 W MAIN ST
DOTHAN AL
36305-1056
US

IV. Provider business mailing address

PO BOX 6907
DOTHAN AL
36302-6907
US

V. Phone/Fax

Practice location:
  • Phone: 334-793-5000
  • Fax: 334-793-4613
Mailing address:
  • Phone: 334-793-5000
  • Fax: 334-793-4613

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QL0400X
TaxonomyLithotripsy Clinic/Center
License Number11810
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number10355
License Number StateAL

VII. Legacy identifiers

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

# 1
Identifier00000745A
Identifier TypeMEDICAID
Identifier StateGA
Identifier Issuer
# 2
IdentifierESW0004L
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 3
Identifier010209100
Identifier TypeMEDICAID
Identifier StateFL
Identifier Issuer
# 4
IdentifierHOS0055H
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 5
Identifier113673800
Identifier TypeMEDICAID
Identifier StateFL
Identifier IssuerFlorida Medicaid Provider ID

VIII. Authorized Official

Name: PAULA LALOR
Title or Position: DIRECTOR/DELEGATED OFFICIAL
Credential:
Phone: 629-215-3953