=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821504598
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLES D. RUBLEY DBA BEAVERTON MEDICAL CLINIC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/18/2017
-----------------------------------------------------
Last Update Date | 04/06/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 12815 US HWY 278
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35544
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-606-1200
-----------------------------------------------------
Fax | 205-606-1202
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 38
-----------------------------------------------------
City | BEAVERTON
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35544-0038
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-606-1200
-----------------------------------------------------
Fax | 205-606-1202
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER / PROVIDER
-----------------------------------------------------
Name | MR. CHARLES D RUBLEY
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 205-606-1200
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 1-081378
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------