Healthcare Provider Details

I. General information

NPI: 1043362734
Provider Name (Legal Business Name): PHYSICAL EXPRESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 03/20/2025
Certification Date: 03/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4081 ALABAMA HWY 14
MILLBROOK AL
36054
US

IV. Provider business mailing address

PO BOX 688
MILLBROOK AL
36054-0014
US

V. Phone/Fax

Practice location:
  • Phone: 334-285-3222
  • Fax: 334-285-6555
Mailing address:
  • Phone: 334-285-3222
  • Fax: 334-285-6555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. JADE LANE
Title or Position: CREDENTIALING MANAGER
Credential:
Phone: 334-567-4311