Provider Demographics
NPI:1184830762
Name:RANBURNE COMMUNITY CLINIC
Entity Type:Organization
Organization Name:RANBURNE COMMUNITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:EDWARDS
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:770-258-7060
Mailing Address - Street 1:22931 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:RANBURNE
Mailing Address - State:AL
Mailing Address - Zip Code:36273-4114
Mailing Address - Country:US
Mailing Address - Phone:256-568-9646
Mailing Address - Fax:256-568-9647
Practice Address - Street 1:22931 MAIN ST
Practice Address - Street 2:
Practice Address - City:RANBURNE
Practice Address - State:AL
Practice Address - Zip Code:36273-4114
Practice Address - Country:US
Practice Address - Phone:256-568-9646
Practice Address - Fax:256-568-9647
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-14
Last Update Date:2007-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-092465363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALP18491Medicare UPIN
ALL216Medicare PIN