Basic Information
| Provider Information | |||||||||
| NPI: | 1780953588 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTHEASTERN BALANCE CENTERS LLC | ||||||||
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| OtherOrganizationName: | SOUTHEASTERN BALANCE CENTERS OF PRATTVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2257 TAYLOR RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | MONTGOMERY | ||||||||
| State: | AL | ||||||||
| PostalCode: | 361177790 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342709914 | ||||||||
| FaxNumber: | 3342703195 | ||||||||
| Practice Location | |||||||||
| Address1: | 660 MCQUEEN SMITH RD N | ||||||||
| Address2: | SUITE F | ||||||||
| City: | PRATTVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360667554 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3343588666 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2011 | ||||||||
| LastUpdateDate: | 12/22/2011 | ||||||||
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| AuthorizedOfficialLastName: | GARNETT | ||||||||
| AuthorizedOfficialFirstName: | TOMMY | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3345143466 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | DPM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Podiatric Medicine & Surgery Service Providers | Podiatrist |
No ID Information.