=====================================================
General NPI Number Information
=====================================================
NPI Number | 1841377587
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/01/2006
-----------------------------------------------------
Last Update Date | 07/27/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 705 20TH AVE E
-----------------------------------------------------
City | JASPER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35501-4071
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 205-221-9775
-----------------------------------------------------
Fax | 205-221-8810
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 MONROE ST THE RSA TOWER, SUITE 1200
-----------------------------------------------------
City | MONTGOMERY
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36104-3735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-206-5341
-----------------------------------------------------
Fax | 334-206-5724
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | STATE HOME CARE DIRECTOR
-----------------------------------------------------
Name | GROVER T WEDGEWORTH
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 334-206-5341
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------