Healthcare Provider Details

I. General information

NPI: 1598005910
Provider Name (Legal Business Name): TLM HEADQUATERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2013
Last Update Date: 02/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1023 MEDICAL CENTER PKWY SUITE 401
SELMA AL
36701-6780
US

IV. Provider business mailing address

1023 MEDICAL CENTER PKWY SUITE 401
SELMA AL
36701-6780
US

V. Phone/Fax

Practice location:
  • Phone: 334-875-7173
  • Fax: 860-899-6112
Mailing address:
  • Phone: 334-875-7173
  • Fax: 860-899-6112

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number28410
License Number StateAL

VIII. Authorized Official

Name: MS. JANET ESTHER HILTON
Title or Position: ORGANIZER
Credential:
Phone: 334-875-7173