Healthcare Provider Details

I. General information

NPI: 1437159290
Provider Name (Legal Business Name): PHP OF ALABAMA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

62 RED EAGLE PKWY
WETUMPKA AL
36092-2052
US

IV. Provider business mailing address

62 RED EAGLE PKWY
WETUMPKA AL
36092-2052
US

V. Phone/Fax

Practice location:
  • Phone: 334-567-3729
  • Fax: 334-514-6776
Mailing address:
  • Phone: 334-567-3729
  • Fax: 334-514-6776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number480
License Number StateAL

VIII. Authorized Official

Name: MR. JON BURNS
Title or Position: ADMINISTRATOR
Credential:
Phone: 334-567-3729