Basic Information
| Provider Information | |||||||||
| NPI: | 1346601630 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RESTORE FLORALA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 245 CAHABA VALLEY PKWY | ||||||||
| Address2: | |||||||||
| City: | PELHAM | ||||||||
| State: | AL | ||||||||
| PostalCode: | 351242216 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 23621 GOLDENROD AVE | ||||||||
| Address2: | |||||||||
| City: | FLORALA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 364423652 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2059426820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/14/2016 | ||||||||
| LastUpdateDate: | 03/14/2016 | ||||||||
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| AuthorizedOfficialLastName: | KNOWLES | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 2059426820 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | 011220 | 01 | AL | BCBS | OTHER | 11968 | 01 | AL | AL STATE BORAD OF HEALTH | OTHER |