=====================================================
General NPI Number Information
=====================================================
NPI Number | 1114198892
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LOVELY WOUND CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/20/2008
-----------------------------------------------------
Last Update Date | 03/20/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 701 UNIVERSITY BLVD E 2ND FLOOR
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35401-2086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-750-5430
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 701 UNIVERSITY BLVD E 2ND FLOOR
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35401-2086
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | PERRY LOVELY
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 205-750-5430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2083P0011X
-----------------------------------------------------
Taxonomy Name | Undersea and Hyperbaric Medicine (Preventive Medicine) Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------