Healthcare Provider Details

I. General information

NPI: 1013363225
Provider Name (Legal Business Name): SELFRECOVERY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/05/2016
Last Update Date: 05/05/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 N LANIER AVE
LANETT AL
36863-2014
US

IV. Provider business mailing address

106 N LANIER AVE
LANETT AL
36863-2014
US

V. Phone/Fax

Practice location:
  • Phone: 334-644-6848
  • Fax: 334-644-5443
Mailing address:
  • Phone: 334-644-6848
  • Fax: 334-644-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number13352
License Number StateAL

VIII. Authorized Official

Name: GAIL M JONES
Title or Position: OFFICE
Credential:
Phone: 334-341-1249