Healthcare Provider Details

I. General information

NPI: 1740900711
Provider Name (Legal Business Name): ELIZABETH GRACE STORIE LAT, ATC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2022
Last Update Date: 02/21/2024
Certification Date: 02/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2901 NORTHRIDGE RD
TUSCALOOSA AL
35406-3665
US

IV. Provider business mailing address

12458 TIMBERLANE RD
RALPH AL
35480-9103
US

V. Phone/Fax

Practice location:
  • Phone: 205-886-3832
  • Fax:
Mailing address:
  • Phone: 205-886-3832
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PS0010X
TaxonomySports Medicine (Emergency Medicine) Physician
License Number2847
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: