Provider Demographics
NPI:1477040483
Name:PETERSVILLE FAMILY CARE, LLC
Entity Type:Organization
Organization Name:PETERSVILLE FAMILY CARE, LLC
Other - Org Name:PETERSVILLE FAMILY CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:256-275-7125
Mailing Address - Street 1:2929 CLOVERDALE RD UNIT D
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35633-1505
Mailing Address - Country:US
Mailing Address - Phone:256-275-7125
Mailing Address - Fax:256-275-7254
Practice Address - Street 1:2929 CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35633
Practice Address - Country:US
Practice Address - Phone:256-366-3551
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-16
Last Update Date:2018-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-01128207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1265837769OtherINDIVIDUAL NPI