=====================================================
General NPI Number Information
=====================================================
NPI Number | 1356927594
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY OF HOPE HEALTH CLINIC- A VOLUNTEERS IN MEDICINE CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/18/2021
-----------------------------------------------------
Last Update Date | 09/03/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2692 PELHAM PKWY STE E
-----------------------------------------------------
City | PELHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35124-1337
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-644-8640
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 177
-----------------------------------------------------
City | PELHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35124-0177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-644-8641
-----------------------------------------------------
Fax | 205-574-3128
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | JUSTIN ROYCE JOHNSTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 205-644-8641
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QC1500X
-----------------------------------------------------
Taxonomy Name | Community Health Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------