Healthcare Provider Details

I. General information

NPI: 1740232982
Provider Name (Legal Business Name): TRIAD OF ALABAMA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2006
Last Update Date: 04/14/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2423 MARTIN LUTHER KING JR BLVD
PANAMA CITY FL
32405-4405
US

IV. Provider business mailing address

PO BOX 1964
DOTHAN AL
36302-1964
US

V. Phone/Fax

Practice location:
  • Phone: 334-794-5000
  • Fax:
Mailing address:
  • Phone: 334-794-5000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number782
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number782
License Number StateAL

VIII. Authorized Official

Name: DEBBIE BREWER
Title or Position: DIRECTOR, PROVIDER ENROLLMENT
Credential:
Phone: 615-465-7626