Healthcare Provider Details

I. General information

NPI: 1932277050
Provider Name (Legal Business Name): PROVIDENCE HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/30/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6351 WOODSIDE DR
THEODORE AL
36582-6061
US

IV. Provider business mailing address

6351 WOODSIDE DR
THEODORE AL
36582-6061
US

V. Phone/Fax

Practice location:
  • Phone: 251-442-2361
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code283X00000X
TaxonomyRehabilitation Hospital
License Number
License Number State

VIII. Authorized Official

Name: MISS JINNI L FRISBEY
Title or Position: CERTIFIED HEAD ATHLETIC TRAINER
Credential: MED, ATC
Phone: 251-442-2361