Provider Demographics
NPI:1225769193
Name:SRD TUSCUMBIA PLLC
Entity Type:Organization
Organization Name:SRD TUSCUMBIA PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-320-5903
Mailing Address - Street 1:PO BOX 740979
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-7423
Mailing Address - Country:US
Mailing Address - Phone:256-383-4990
Mailing Address - Fax:
Practice Address - Street 1:121 E 6TH ST
Practice Address - Street 2:
Practice Address - City:TUSCUMBIA
Practice Address - State:AL
Practice Address - Zip Code:35674-2413
Practice Address - Country:US
Practice Address - Phone:256-383-0377
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-22
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty