=====================================================
General NPI Number Information
=====================================================
NPI Number | 1952773749
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEADACHE & TMJ CENTER THERAPY OF THE SOUTHEAST LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2015
-----------------------------------------------------
Last Update Date | 10/20/2015
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1609 W MAIN ST SUITE 201
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36301-1362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-793-6060
-----------------------------------------------------
Fax | 334-836-0199
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1609 W MAIN ST SUITE 201
-----------------------------------------------------
City | DOTHAN
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 36301-1362
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 334-793-6060
-----------------------------------------------------
Fax | 334-836-0199
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. JACK BRENT MCFARLAND
-----------------------------------------------------
Credential | D.M.D
-----------------------------------------------------
Telephone | 334-793-6060
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 1223X0400X
-----------------------------------------------------
Taxonomy Name | Orthodontics and Dentofacial Orthopedics Dentistry
-----------------------------------------------------
License Number | 3054
-----------------------------------------------------
License Number State | AL
-----------------------------------------------------