Healthcare Provider Details

I. General information

NPI: 1558894576
Provider Name (Legal Business Name): FIVE STAR DIAGNOSTICS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/06/2017
Last Update Date: 02/27/2020
Certification Date: 02/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1028 GRANDE VIEW PASS
MAYLENE AL
35114-4004
US

IV. Provider business mailing address

1028 GRANDE VIEW PASS
MAYLENE AL
35114-4004
US

V. Phone/Fax

Practice location:
  • Phone: 205-478-1200
  • Fax:
Mailing address:
  • Phone: 205-478-1200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: CEDRIC SHANNON
Title or Position: OWNER/CEO
Credential:
Phone: 205-478-1200