Provider Demographics
NPI:1518359025
Name:DYSAUTONOMIA MVP CENTER, LLC.
Entity Type:Organization
Organization Name:DYSAUTONOMIA MVP CENTER, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIMBERLEE
Authorized Official - Middle Name:F
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:CBCS
Authorized Official - Phone:205-467-4969
Mailing Address - Street 1:2470 ROCKY RIDGE RD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-2833
Mailing Address - Country:US
Mailing Address - Phone:205-467-4969
Mailing Address - Fax:
Practice Address - Street 1:2470 ROCKY RIDGE RD
Practice Address - Street 2:SUITE 200
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-2833
Practice Address - Country:US
Practice Address - Phone:205-529-5658
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-02-21
Last Update Date:2015-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL9924207Q00000X
AL14740207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty