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General NPI Number Information
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NPI Number | 1649569963
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Entity Type | Organization
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Legal Business Name | COMPLETE HEALTH & WELLNESS OF AL, INC
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Dates
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Enumeration Date | 04/07/2011
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Last Update Date | 04/11/2011
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Provider Practice Location Address
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Address Line | 819 MIMOSA PARK RD SUITE C
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City | TUSCALOOSA
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State | AL
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Zip | 35405-4839
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Country | US
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Telephone | 205-343-7743
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Fax | 205-752-7513
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Provider Business Mailing Address
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Address Line | 819 MIMOSA PARK ROAD SUITE C
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City | TUSCALOOSA
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State | AL
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Zip | 35405
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Country | US
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Telephone | 205-343-7743
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Fax | 205-752-7513
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Authorized Official
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Title or Position | PRES
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Name | BRENT ALAN TIDWELL
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Credential |
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Telephone | 205-343-7743
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 1-079816
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License Number State | AL
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 27746
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License Number State | AL
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