MEDICARE: VAXINALL 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	172V00000X	Community Health Worker
2	251K00000X	Public Health or Welfare Agency

General Provider Information

NPI Number	:	1992993562
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VAXINALL LLC.

Provider Business Mailing Address
First Line	:	648 PARK AVE
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36106-1837
Country	:	US
Telephone Number	:	334-294-9342
Fax Number	:

Provider Business Practice Location Address
First Line	:	648 PARK AVE
Second Line	:
City	:	MONTGOMERY
State	:	AL
Zip	:	36106-1837
Country	:	US
Telephone Number	:	334-294-9342
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MR. DON LAND KELLER
Credential	:	CRNA
Telephone Number	:	334-294-9342

Provider Enumeration Date	:	10/09/2007
Last Update Date	:	10/09/2007

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