Healthcare Provider Details

I. General information

NPI: 1427566181
Provider Name (Legal Business Name): CLINIC OF GADSDEN, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 RAINBOW DR STE B
GADSDEN AL
35901-5319
US

IV. Provider business mailing address

PO BOX 860
GADSDEN AL
35902-0860
US

V. Phone/Fax

Practice location:
  • Phone: 256-646-6358
  • Fax:
Mailing address:
  • Phone: 256-646-6358
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberDO.1762
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code261QU0200X
TaxonomyUrgent Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JONATHAN HUBBARD FULLER
Title or Position: CEO
Credential: DO
Phone: 256-646-6358