Healthcare Provider Details

I. General information

NPI: 1609602028
Provider Name (Legal Business Name): CAMERON BUTLER CARPENTER
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2024
Last Update Date: 09/11/2024
Certification Date: 09/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 HOSPITAL ST
MOULTON AL
35650-1268
US

IV. Provider business mailing address

284 HIGHLAND DR
MOULTON AL
35650-4110
US

V. Phone/Fax

Practice location:
  • Phone: 256-974-1146
  • Fax:
Mailing address:
  • Phone: 256-616-8658
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA11916
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: