Healthcare Provider Details

I. General information

NPI: 1770020372
Provider Name (Legal Business Name): CORIZON HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2017
Last Update Date: 01/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2690 MARION SPILLWAY RD
ELMORE AL
36025-1531
US

IV. Provider business mailing address

2690 MARION SPILLWAY RD
ELMORE AL
36025-1531
US

V. Phone/Fax

Practice location:
  • Phone: 334-567-2221
  • Fax:
Mailing address:
  • Phone: 334-567-2221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License Number1-107743
License Number StateAL

VIII. Authorized Official

Name: ANITA WILSON
Title or Position: PHYSICAN
Credential: M.D.
Phone: 334-207-9988