Healthcare Provider Details

I. General information

NPI: 1902984032
Provider Name (Legal Business Name): MILLPORT FAMILY PRACTICE CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13530 HIGHWAY 96
MILLPORT AL
35576-2522
US

IV. Provider business mailing address

13530 HIGHWAY 96
MILLPORT AL
35576-2522
US

V. Phone/Fax

Practice location:
  • Phone: 205-662-5784
  • Fax:
Mailing address:
  • Phone: 205-662-5784
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MR. ROBERT ENOCH SWANSON
Title or Position: MANAGING PARTNER
Credential:
Phone: 205-662-5784