Healthcare Provider Details

I. General information

NPI: 1649569963
Provider Name (Legal Business Name): COMPLETE HEALTH & WELLNESS OF AL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/07/2011
Last Update Date: 04/11/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

819 MIMOSA PARK RD SUITE C
TUSCALOOSA AL
35405-4839
US

IV. Provider business mailing address

819 MIMOSA PARK ROAD SUITE C
TUSCALOOSA AL
35405
US

V. Phone/Fax

Practice location:
  • Phone: 205-343-7743
  • Fax: 205-752-7513
Mailing address:
  • Phone: 205-343-7743
  • Fax: 205-752-7513

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-079816
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number27746
License Number StateAL

VIII. Authorized Official

Name: BRENT ALAN TIDWELL
Title or Position: PRES
Credential:
Phone: 205-343-7743