Provider Demographics
NPI:1376699116
Name:COMMUNITY SERVICE PROGRAMS OF WEST AL INC
Entity Type:Organization
Organization Name:COMMUNITY SERVICE PROGRAMS OF WEST AL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SUPERVISOR
Authorized Official - Prefix:
Authorized Official - First Name:MARY BETH
Authorized Official - Middle Name:
Authorized Official - Last Name:VICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-752-0476
Mailing Address - Street 1:601 17TH STREET
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-6311
Mailing Address - Country:US
Mailing Address - Phone:205-752-0476
Mailing Address - Fax:205-752-8122
Practice Address - Street 1:2002 MCFARLAND BLVD E
Practice Address - Street 2:SUITE 209
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404
Practice Address - Country:US
Practice Address - Phone:205-752-0476
Practice Address - Fax:205-752-8122
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-26
Last Update Date:2008-04-30
Deactivation Date:2007-02-14
Deactivation Code:
Reactivation Date:2008-04-30
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL591500002MedicaidTCM PROVIDER NUMBER