MEDICARE: CAPSTONE MEDICAL RESOURCES, LLC

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
1	103TC0700X	Clinical Psychologist		AL

General Provider Information

NPI Number	:	1104364074
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAPSTONE MEDICAL RESOURCES, LLC

Provider Business Mailing Address
First Line	:	300 CORNWALL
Second Line	:
City	:	MAYLENE
State	:	AL
Zip	:	35114-5455
Country	:	US
Telephone Number	:	205-503-1642
Fax Number	:

Provider Business Practice Location Address
First Line	:	3500 BLUE LAKE DR
Second Line	:	STE 340
City	:	VESTAVIA
State	:	AL
Zip	:	35243-1907
Country	:	US
Telephone Number	:	205-503-1643
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	DR. SHARON D WALTZ
Credential	:	PSY.D.
Telephone Number	:	205-503-1643

Provider Enumeration Date	:	02/10/2017
Last Update Date	:	02/10/2017

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