=====================================================
General NPI Number Information
=====================================================
NPI Number | 1043231079
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOURROUX THERAPY SERVICES, L.L.C.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/23/2006
-----------------------------------------------------
Last Update Date | 02/04/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2743 BOB WALLACE AVE SW
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35805-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-534-8672
-----------------------------------------------------
Fax | 256-539-9755
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2743 BOB WALLACE AVE SW
-----------------------------------------------------
City | HUNTSVILLE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35805-4103
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-534-8672
-----------------------------------------------------
Fax | 256-539-9755
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. WILLIAM KEITH WATSON
-----------------------------------------------------
Credential | CPO
-----------------------------------------------------
Telephone | 256-534-8672
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 18990
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------