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General NPI Number Information
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NPI Number | 1063104511
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Entity Type | Organization
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Legal Business Name | MENTORUP LIFE LAB & CLINIC
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Dates
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Enumeration Date | 05/23/2023
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Last Update Date | 05/23/2023
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Provider Practice Location Address
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Address Line | 535 JACK WARNER PKWY NE STE G2
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City | TUSCALOOSA
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State | AL
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Zip | 35404-5715
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Country | US
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Telephone | 205-771-2261
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Fax |
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Provider Business Mailing Address
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Address Line | 4202 20TH ST NE
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City | TUSCALOOSA
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State | AL
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Zip | 35404-1502
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Country | US
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Telephone | 205-771-2261
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Fax |
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Authorized Official
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Title or Position | MEDICAL DIRECTOR
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Name | ELLORY KATE JOHNSON
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Credential | MD
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Telephone | 205-771-2261
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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