Healthcare Provider Details

I. General information

NPI: 1265701122
Provider Name (Legal Business Name): HEALTHSOURCE OF HARVEST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2011
Last Update Date: 12/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5850 HIGHWAY 53 STE. N
HARVEST AL
35749-4301
US

IV. Provider business mailing address

5850 HWY 53 SUITE N
HARVEST AL
35749-4302
US

V. Phone/Fax

Practice location:
  • Phone: 256-852-2000
  • Fax: 256-852-2232
Mailing address:
  • Phone: 256-852-2000
  • Fax: 256-852-2232

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code111N00000X
TaxonomyChiropractor
License Number#2111
License Number StateAL

VIII. Authorized Official

Name: MRS. AMY CATHERINE LAWRENCE
Title or Position: PARTNER/CHIROPRACTOR
Credential: D.C.
Phone: 256-852-2000