Healthcare Provider Details

I. General information

NPI: 1710755954
Provider Name (Legal Business Name): MARY TYLER ARMINIO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/18/2023
Last Update Date: 12/18/2023
Certification Date: 12/18/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2450 VILLAGE PROFESSIONAL DR N
OPELIKA AL
36801-4734
US

IV. Provider business mailing address

2450 VILLAGE PROFESSIONAL DR N
OPELIKA AL
36801-4734
US

V. Phone/Fax

Practice location:
  • Phone: 334-528-1964
  • Fax:
Mailing address:
  • Phone: 334-528-1964
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4424
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: