Healthcare Provider Details

I. General information

NPI: 1770875460
Provider Name (Legal Business Name): ANISKA PROFESSIONAL AND EDUCATIONAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2011
Last Update Date: 05/20/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

130 ANISKA DRIVE
GADSDEN AL
35901
US

IV. Provider business mailing address

130 ANISKA DR
GADSDEN AL
35901-9133
US

V. Phone/Fax

Practice location:
  • Phone: 256-613-2709
  • Fax:
Mailing address:
  • Phone: 256-613-2709
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number30452
License Number StateAL
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number30452
License Number StateAL

VIII. Authorized Official

Name: DR. RENITA GAIL BROWN
Title or Position: PRESIDENT
Credential: MD
Phone: 256-613-2709