Healthcare Provider Details

I. General information

NPI: 1407886732
Provider Name (Legal Business Name): NORTHGATE SERVICES OF MISSOURI LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/03/2006
Last Update Date: 10/11/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

961 FAIRFAX PARK
TUSCALOOSA AL
35406-2805
US

IV. Provider business mailing address

961 FAIRFAX PARK
TUSCALOOSA AL
35406-2805
US

V. Phone/Fax

Practice location:
  • Phone: 205-345-8858
  • Fax: 205-345-7991
Mailing address:
  • Phone: 205-345-8858
  • Fax: 205-345-7991

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number630016343
License Number StateAL

VIII. Authorized Official

Name: CLAUDE E LEE
Title or Position: VICE PRESIDENT CFO
Credential:
Phone: 205-391-3600