=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881956290
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MENS EXECUTIVE HEALTH SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/12/2012
-----------------------------------------------------
Last Update Date | 06/12/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2798 JOHN HAWKINS PKWY STE 128
-----------------------------------------------------
City | HOOVER
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35244-3108
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-328-2006
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1250 WATTS RD
-----------------------------------------------------
City | BOWDON
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30108-2757
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | NURSE PRACTITIONER
-----------------------------------------------------
Name | MR. ROBERT CHRIS SALTER
-----------------------------------------------------
Credential | CPRN
-----------------------------------------------------
Telephone | 770-328-2006
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 1071631
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | AL 24557
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | AL 20705
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------