=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275899031
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE FAMILY FIRST HEALTH CLINIC AT THE ROCK
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/05/2012
-----------------------------------------------------
Last Update Date | 04/05/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1955 SAND ROCK AVE
-----------------------------------------------------
City | SANDROCK
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35983-4327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-523-6288
-----------------------------------------------------
Fax | 256-523-6290
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1955 SAND ROCK AVE
-----------------------------------------------------
City | SANDROCK
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35983-4327
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-523-6288
-----------------------------------------------------
Fax | 256-523-6290
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | SAMMYE L BRADLEY
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 256-523-6288
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------