Healthcare Provider Details

I. General information

NPI: 1154606861
Provider Name (Legal Business Name): CRENSHAW FAMILY CARE CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/13/2011
Last Update Date: 06/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

58 ROY BEALL DR
LUVERNE AL
36049-6800
US

IV. Provider business mailing address

PO BOX 5013
MONTGOMERY AL
36103-5013
US

V. Phone/Fax

Practice location:
  • Phone: 334-335-1212
  • Fax:
Mailing address:
  • Phone: 334-386-0343
  • Fax: 334-386-0382

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: VICKI F LAWRENSON
Title or Position: MEMBER/MANAGER
Credential:
Phone: 334-386-0343