Provider Demographics
NPI:1407263650
Name:FAMILY HEALTH & WELLNESS CENTER L.L.C.
Entity Type:Organization
Organization Name:FAMILY HEALTH & WELLNESS CENTER L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAVISSON
Authorized Official - Middle Name:
Authorized Official - Last Name:EDMOND
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-454-8620
Mailing Address - Street 1:671 SNOW ST
Mailing Address - Street 2:
Mailing Address - City:OXFORD
Mailing Address - State:AL
Mailing Address - Zip Code:36203-1212
Mailing Address - Country:US
Mailing Address - Phone:256-454-8620
Mailing Address - Fax:
Practice Address - Street 1:671 SNOW ST
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:AL
Practice Address - Zip Code:36203-1212
Practice Address - Country:US
Practice Address - Phone:256-454-8620
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-21
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALMD30459207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL141772Medicaid