=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982554978
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ETERNA PRIMARY CARE OF ALABAMA LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/30/2026
-----------------------------------------------------
Last Update Date | 01/30/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4941 MONTEVALLO RD
-----------------------------------------------------
City | IRONDALE
-----------------------------------------------------
State | AL
-----------------------------------------------------
Zip | 35210-2418
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 606-306-7706
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1621 GALLERIA BLVD
-----------------------------------------------------
City | BRENTWOOD
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37027-2926
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF OPERATING OFFICER
-----------------------------------------------------
Name | PENNY LOGAN
-----------------------------------------------------
Credential | MSN, MBA, APRN
-----------------------------------------------------
Telephone | 606-306-7706
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208D00000X
-----------------------------------------------------
Taxonomy Name | General Practice Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------