Healthcare Provider Details

I. General information

NPI: 1518359025
Provider Name (Legal Business Name): DYSAUTONOMIA MVP CENTER, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/21/2015
Last Update Date: 02/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2470 ROCKY RIDGE RD SUITE 200
VESTAVIA AL
35243-2833
US

IV. Provider business mailing address

2470 ROCKY RIDGE RD SUITE 200
VESTAVIA AL
35243-2833
US

V. Phone/Fax

Practice location:
  • Phone: 205-529-5658
  • Fax:
Mailing address:
  • Phone: 205-467-4969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number9924
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number14740
License Number StateAL

VIII. Authorized Official

Name: MRS. KIMBERLEE F SMITH
Title or Position: OFFICE MANAGER
Credential: CBCS
Phone: 205-467-4969