=====================================================
General NPI Number Information
=====================================================
NPI Number | 1194207084
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ELKMONT COMMUNITY CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/06/2018
-----------------------------------------------------
Last Update Date | 01/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 25442 AL HIGHWAY 127
-----------------------------------------------------
City | ELKMONT
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35620-6608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-732-3712
-----------------------------------------------------
Fax | 256-732-3714
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 25442 AL HIGHWAY 127
-----------------------------------------------------
City | ELKMONT
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35620-6608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-732-3712
-----------------------------------------------------
Fax | 256-732-3714
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | SEBRINA B HOLT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 256-216-9648
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------