Healthcare Provider Details

I. General information

NPI: 1376266726
Provider Name (Legal Business Name): BLUE LAKE HEALTH ALABAMA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2022
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 HELTON CT
FLORENCE AL
35630-1464
US

IV. Provider business mailing address

3104 BLUE LAKE DR STE 110
VESTAVIA AL
35243-2372
US

V. Phone/Fax

Practice location:
  • Phone: 256-760-0672
  • Fax:
Mailing address:
  • Phone: 205-977-1949
  • Fax: 205-977-1933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: ROBERT PATRICK JR.
Title or Position: CEO
Credential:
Phone: 205-977-1949