Healthcare Provider Details

I. General information

NPI: 1417605585
Provider Name (Legal Business Name): EDUCATION AVENUE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2022
Last Update Date: 05/16/2022
Certification Date: 05/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5375 TAMMY LITTLE DR STE 3
SECTION AL
35771-7257
US

IV. Provider business mailing address

5375 TAMMY LITTLE DR STE 3
SECTION AL
35771-7257
US

V. Phone/Fax

Practice location:
  • Phone: 256-242-3261
  • Fax:
Mailing address:
  • Phone: 256-242-3261
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MONICA PAYNE
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential: PHARMD
Phone: 256-228-7179