Healthcare Provider Details

I. General information

NPI: 1881666204
Provider Name (Legal Business Name): PERFECTO TAN LPC
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 02/02/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5750A SOUTHLAND DR
MOBILE AL
36693-3316
US

IV. Provider business mailing address

2400 GORDON SMITH DR
MOBILE AL
36617-2319
US

V. Phone/Fax

Practice location:
  • Phone: 251-662-7290
  • Fax:
Mailing address:
  • Phone: 251-473-4423
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number1754
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: