Provider Demographics
NPI:1154832921
Name:IMC OF ALABAMA
Entity Type:Organization
Organization Name:IMC OF ALABAMA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:MARK
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:PT, DIP MDT
Authorized Official - Phone:850-656-1837
Mailing Address - Street 1:2615 CENTENNIAL BLVD.
Mailing Address - Street 2:SUITE 101
Mailing Address - City:TALLAHASSEE
Mailing Address - State:FL
Mailing Address - Zip Code:32308-0536
Mailing Address - Country:US
Mailing Address - Phone:850-656-1837
Mailing Address - Fax:850-877-2917
Practice Address - Street 1:5101 21ST STREET
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401
Practice Address - Country:US
Practice Address - Phone:850-656-1837
Practice Address - Fax:850-877-2917
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:COSPT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-10-19
Last Update Date:2017-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty