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General NPI Number Information
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NPI Number | 1841499357
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Entity Type | Organization
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Legal Business Name | TRICOUNTY TOTAL CARE
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Dates
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Enumeration Date | 07/13/2007
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Last Update Date | 07/13/2007
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Provider Practice Location Address
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Address Line | 5300 OAK TREE RD STE H
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City | MILLBROOK
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State | AL
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Zip | 36054-2218
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Country | US
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Telephone | 334-285-8282
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Fax | 334-261-6113
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Provider Business Mailing Address
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Address Line | 5300 OAK TREE RD STE H
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City | MILLBROOK
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State | AL
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Zip | 36054-2219
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Country | US
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Telephone | 334-285-8282
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Fax | 334-261-6113
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Authorized Official
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Title or Position | BUSINESS OFFICE MANAGER
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Name | LISA JACKSON
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Credential |
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Telephone | 334-265-7075
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207R00000X
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Taxonomy Name | Internal Medicine Physician
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License Number | 21769
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License Number State | AL
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