Provider Demographics
NPI:1356464036
Name:SOUTHLAND TOTAL HEALTHCARE SYSTEMS, INC.
Entity Type:Organization
Organization Name:SOUTHLAND TOTAL HEALTHCARE SYSTEMS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:WILATRA
Authorized Official - Middle Name:
Authorized Official - Last Name:AWONIYI
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:256-353-0410
Mailing Address - Street 1:2046 BELTLINE RD SW
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-5549
Mailing Address - Country:US
Mailing Address - Phone:256-353-0410
Mailing Address - Fax:256-353-0649
Practice Address - Street 1:2046 BELTLINE RD SW
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-5549
Practice Address - Country:US
Practice Address - Phone:256-353-0410
Practice Address - Fax:256-353-0649
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-09
Last Update Date:2007-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL39121223G0001X
AL9604207VH0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207VH0002XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyHospice and Palliative MedicineGroup - Multi-Specialty
No1223G0001XDental ProvidersDentistGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529702900Medicaid