Provider Demographics
NPI:1427229624
Name:BREWER PORCH CHILDREN'S CENTER
Entity Type:Organization
Organization Name:BREWER PORCH CHILDREN'S CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:YVONNE
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:SEGREST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-348-9366
Mailing Address - Street 1:2501 WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35404-5028
Mailing Address - Country:US
Mailing Address - Phone:205-348-7236
Mailing Address - Fax:205-348-9368
Practice Address - Street 1:2501 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35404-5028
Practice Address - Country:US
Practice Address - Phone:205-348-7236
Practice Address - Fax:205-348-9368
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:UNIVERSITY OF ALABAMA
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-03-14
Last Update Date:2008-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL330000027Medicaid