Healthcare Provider Details

I. General information

NPI: 1649389610
Provider Name (Legal Business Name): THE HEALTH CARE AUTHORITY OF THE CITY OF ENTERPRISE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 04/17/2023
Certification Date: 04/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 PLAZA DR
ENTERPRISE AL
36330-3311
US

IV. Provider business mailing address

300 PLAZA DR
ENTERPRISE AL
36330-3311
US

V. Phone/Fax

Practice location:
  • Phone: 334-347-9541
  • Fax: 334-347-5070
Mailing address:
  • Phone: 334-347-9541
  • Fax: 334-347-5070

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License NumberN1602
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code332BP3500X
TaxonomyParenteral & Enteral Nutrition Supplies (DME)
License NumberN1602
License Number StateAL
# 3
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN1602
License Number StateAL

VII. Legacy identifiers

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

# 1
Identifier0601900001
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerDME SUPPLIER
# 2
Identifier4753200S
Identifier TypeMEDICAID
Identifier StateAL
Identifier Issuer
# 3
Identifier010605
Identifier TypeOTHER
Identifier StateAL
Identifier IssuerBLUE CROSS/BLUE SHIELD

VIII. Authorized Official

Name: MR. WESLEY M. AVERETT
Title or Position: ADMINISTRATOR
Credential:
Phone: 334-347-9541