Provider Demographics
NPI:1306843305
Name:ETHER BUNNY INC
Entity Type:Organization
Organization Name:ETHER BUNNY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING CONTACT
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:DESVERREAUX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-965-5393
Mailing Address - Street 1:PO BOX 969
Mailing Address - Street 2:
Mailing Address - City:MAGNOLIA SPRINGS
Mailing Address - State:AL
Mailing Address - Zip Code:36555-0969
Mailing Address - Country:US
Mailing Address - Phone:251-965-5393
Mailing Address - Fax:251-971-1029
Practice Address - Street 1:1613 N MCKENZIE ST
Practice Address - Street 2:
Practice Address - City:FOLEY
Practice Address - State:AL
Practice Address - Zip Code:36535-2247
Practice Address - Country:US
Practice Address - Phone:251-965-5393
Practice Address - Fax:251-971-1029
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-05
Last Update Date:2009-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Multi-Specialty
No207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529907430Medicaid
AL529907430Medicaid
ALI567Medicare PIN