Healthcare Provider Details

I. General information

NPI: 1720121395
Provider Name (Legal Business Name): EXTENDED FAMILY MEDICAL CLINIC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2007
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

108 N CATHERINE ST SUITE A
MOBILE AL
36604-1304
US

IV. Provider business mailing address

108 N CATHERINE ST SUITE A
MOBILE AL
36604-1304
US

V. Phone/Fax

Practice location:
  • Phone: 251-438-7170
  • Fax: 251-438-7173
Mailing address:
  • Phone: 251-438-7170
  • Fax: 251-438-7173

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 Code261Q00000X
TaxonomyClinic/Center
License Number1-073404
License Number StateAL

VIII. Authorized Official

Name: ANGELIA DENIESE BLACKMON
Title or Position: MEDICAL DIRECTOR
Credential: CRNP
Phone: 251-438-7170