Healthcare Provider Details

I. General information

NPI: 1306843305
Provider Name (Legal Business Name): ETHER BUNNY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 04/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1613 N MCKENZIE ST
FOLEY AL
36535-2247
US

IV. Provider business mailing address

PO BOX 969
MAGNOLIA SPRINGS AL
36555-0969
US

V. Phone/Fax

Practice location:
  • Phone: 251-965-5393
  • Fax: 251-971-1029
Mailing address:
  • Phone: 251-965-5393
  • Fax: 251-971-1029

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207L00000X
TaxonomyAnesthesiology Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBRA LEE DESVERREAUX
Title or Position: BILLING CONTACT
Credential:
Phone: 251-965-5393