=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467590984
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FELLOWSHIP HOUSE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1625 12TH AVE S
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35205-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-933-2430
-----------------------------------------------------
Fax | 205-933-2475
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1625 12TH AVE S
-----------------------------------------------------
City | BIRMINGHAM
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35205-4709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-933-2430
-----------------------------------------------------
Fax | 205-933-2475
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF PROGRAMS
-----------------------------------------------------
Name | MR. JIM COUNTS
-----------------------------------------------------
Credential | SCAC, NCAC II
-----------------------------------------------------
Telephone | 205-933-2430
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------