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NPI Code Detail

MEDICARE: ANTHONY DWAIN PETTUS JR.

MEDICARE: ANTHONY DWAIN PETTUS JR.
Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

# Taxonomy Code Taxonomy License Number License Number State
1171M00000XCase Manager/Care CoordinatorTN
2106S00000XBehavior Technician19-88268AL

General Provider Information

NPI Number : 1023518214
Entity Type Code : Individual
Provider Name (Legal Business Name) : ANTHONY DWAIN PETTUS JR.
Provider Business Mailing Address
First Line : 100 SPENRYN DR
Second Line :
City : MADISON
State : AL
Zip : 35758-1890
Country : US
Telephone Number : 256-772-4400
Fax Number :
Provider Business Practice Location Address
First Line : 100 SPENRYN DR
Second Line :
City : MADISON
State : AL
Zip : 35758-1890
Country : US
Telephone Number : 256-772-4400
Fax Number :
Authorized Official
Title or Position :
Name :
Credential :
Telephone Number :
Provider Enumeration Date : 02/14/2018
Last Update Date : 06/12/2019

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