Healthcare Provider Details

I. General information

NPI: 1861494841
Provider Name (Legal Business Name): SUSAN MALEIA PERSALL OD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 10/31/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1098 HIGHWAY 31 SW
HARTSELLE AL
35640-2843
US

IV. Provider business mailing address

1098 HIGHWAY 31 SW
HARTSELLE AL
35640-2843
US

V. Phone/Fax

Practice location:
  • Phone: 256-773-4418
  • Fax: 256-773-4422
Mailing address:
  • Phone: 256-773-4418
  • Fax: 256-773-4422

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberS990TA562
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: