Healthcare Provider Details

I. General information

NPI: 1033541719
Provider Name (Legal Business Name): MERRYWOOD LODGE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

280 MT HEBRON RD
ELMORE AL
36025-1526
US

IV. Provider business mailing address

280 MT HEBRON RD
ELMORE AL
36025-1526
US

V. Phone/Fax

Practice location:
  • Phone: 334-567-8484
  • Fax:
Mailing address:
  • Phone: 334-567-8484
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberPTA6755
License Number StateAL

VIII. Authorized Official

Name: AMBER LOUISE BROOKS
Title or Position: LPTA
Credential:
Phone: 334-318-7536