Healthcare Provider Details

I. General information

NPI: 1912377425
Provider Name (Legal Business Name): LOUISE'S PROMISE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2015
Last Update Date: 09/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4240 CAHABA DR
VESTAVIA AL
35243-1600
US

IV. Provider business mailing address

4240 CAHABA DR
VESTAVIA AL
35243-1600
US

V. Phone/Fax

Practice location:
  • Phone: 205-441-3106
  • Fax:
Mailing address:
  • Phone: 205-441-3106
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251T00000X
TaxonomyPACE Provider Organization
License Number15019719
License Number StateAL

VIII. Authorized Official

Name: MISS CAROL RAE SHINNETTE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 205-441-3106