=====================================================
General NPI Number Information
=====================================================
NPI Number | 1851898449
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTH DEKALB PRIMARY CARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/10/2018
-----------------------------------------------------
Last Update Date | 04/17/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 136 COMMERCE AVE
-----------------------------------------------------
City | VALLEY HEAD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35989
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-674-1052
-----------------------------------------------------
Fax | 256-674-1054
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38109 US HIGHWAY 11
-----------------------------------------------------
City | VALLEY HEAD
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35989-4432
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 256-996-0540
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. JOHN MOORE
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 256-996-0540
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------