=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326294000
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | PAIGE CERTIFIED RESIDENTAL FACILITY
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/13/2008
-----------------------------------------------------
Last Update Date | 08/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4617 30TH AVE E
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35405-4407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-633-1698
-----------------------------------------------------
Fax | 205-562-1015
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4617 30TH AVE E
-----------------------------------------------------
City | TUSCALOOSA
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35405-4407
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. REGINALD BERNARD PAIGE SR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-657-3277
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------