Healthcare Provider Details

I. General information

NPI: 1770195737
Provider Name (Legal Business Name): ALABAMA GAME CHANGERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2020
Last Update Date: 08/20/2020
Certification Date: 08/20/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2111 PARKWAY OFFICE CIR STE 150
HOOVER AL
35244-2920
US

IV. Provider business mailing address

2111 PARKWAY OFFICE CIR STE 150
HOOVER AL
35244-2920
US

V. Phone/Fax

Practice location:
  • Phone: 205-914-8733
  • Fax:
Mailing address:
  • Phone: 205-914-8733
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ANGELA P FLETCHER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 205-914-8733