Healthcare Provider Details

I. General information

NPI: 1982103974
Provider Name (Legal Business Name): DCH PROVIDER SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/06/2018
Last Update Date: 03/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 UNIVERSITY BLVD E
TUSCALOOSA AL
35401
US

IV. Provider business mailing address

809 UNIVERSITY BLVD E
TUSCALOOSA AL
35401
US

V. Phone/Fax

Practice location:
  • Phone: 205-333-4528
  • Fax:
Mailing address:
  • Phone: 205-333-4528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MR. DANIEL CLAY CONVILLE
Title or Position: DIRECTOR, PHYSICIAN SERVICES
Credential:
Phone: 205-333-4528