Provider Demographics
NPI:1063686962
Name:L. TERRY PYNES
Entity Type:Organization
Organization Name:L. TERRY PYNES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEONARD
Authorized Official - Middle Name:T
Authorized Official - Last Name:PYNES
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-793-9222
Mailing Address - Street 1:2431 W MAIN ST
Mailing Address - Street 2:STE 501
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36301-1217
Mailing Address - Country:US
Mailing Address - Phone:334-793-9222
Mailing Address - Fax:334-671-0322
Practice Address - Street 1:2431 W MAIN ST
Practice Address - Street 2:STE 501
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-1217
Practice Address - Country:US
Practice Address - Phone:334-793-9222
Practice Address - Fax:334-671-0322
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00008834174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529922330Medicaid
ALC71888Medicare UPIN
AL529922330Medicaid