Healthcare Provider Details

I. General information

NPI: 1255409447
Provider Name (Legal Business Name): SELF-RECOVERY, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/04/2006
Last Update Date: 12/09/2024
Certification Date: 12/09/2024
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: 334-644-5543

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code282N00000X
TaxonomyGeneral Acute Care Hospital
License Number00022660
License Number StateAL

VIII. Authorized Official

Name: TOMMY MOORE
Title or Position: OWNER
Credential: CEO
Phone: 334-644-6848