Healthcare Provider Details

I. General information

NPI: 1568649754
Provider Name (Legal Business Name): BRENDA L CASSELBERRY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2008
Last Update Date: 01/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2121 EXECUTIVE PARK DR
OPELIKA AL
36801-6041
US

IV. Provider business mailing address

PO BOX 1268
AUBURN AL
36831-1268
US

V. Phone/Fax

Practice location:
  • Phone: 334-705-0544
  • Fax: 334-705-0531
Mailing address:
  • Phone: 334-705-0544
  • Fax: 334-705-0548

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number132
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code261QA1903X
TaxonomyAmbulatory Surgical Clinic/Center
License Number132
License Number StateAL

VIII. Authorized Official

Name: DR. BRENDA L CASSELBERRY
Title or Position: PHYSICIAN / PRESIDENT
Credential: DPM
Phone: 334-705-0544