Healthcare Provider Details

I. General information

NPI: 1770769119
Provider Name (Legal Business Name): KNOLLWOOD HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2008
Last Update Date: 02/27/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3151 KNOLLWOOD DR # A
MOBILE AL
36693-2753
US

IV. Provider business mailing address

3151 KNOLLWOOD DR # A
MOBILE AL
36693-2753
US

V. Phone/Fax

Practice location:
  • Phone: 251-661-7608
  • Fax:
Mailing address:
  • Phone: 251-661-7608
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License NumberN4926
License Number StateAL

VIII. Authorized Official

Name: TYGH BROGDON
Title or Position: MANAGER
Credential:
Phone: 770-650-8773