Healthcare Provider Details

I. General information

NPI: 1063988806
Provider Name (Legal Business Name): PICKENS COUNTY PRIMARY CARE, P.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2018
Last Update Date: 02/19/2020
Certification Date: 02/19/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 4TH ST NW
GORDO AL
35466
US

IV. Provider business mailing address

108 4TH AVE SW STE A
REFORM AL
35481-8018
US

V. Phone/Fax

Practice location:
  • Phone: 205-375-6251
  • Fax: 205-375-9064
Mailing address:
  • Phone: 205-375-6251
  • Fax: 205-375-9064

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JULIA L BOOTHE
Title or Position: OWNER
Credential: MD
Phone: 205-792-6701