Healthcare Provider Details

I. General information

NPI: 1801040621
Provider Name (Legal Business Name): GLENDA PEACOCK DERAMUS NBC HIS
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/06/2008
Last Update Date: 11/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2809 CHESTNUT ST
MONTGOMERY AL
36107-3007
US

IV. Provider business mailing address

2809 CHESTNUT ST
MONTGOMERY AL
36107-3007
US

V. Phone/Fax

Practice location:
  • Phone: 334-262-7553
  • Fax: 334-261-3132
Mailing address:
  • Phone: 334-262-7553
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code237700000X
TaxonomyHearing Instrument Specialist
License Number11284
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: