Provider Demographics
NPI:1578919890
Name:MOBILE COUNTY BOARD OF HEALTH
Entity Type:Organization
Organization Name:MOBILE COUNTY BOARD OF HEALTH
Other - Org Name:CITRONELLE DENTAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:WARREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:251-690-8158
Mailing Address - Street 1:251 N BAYOU ST
Mailing Address - Street 2:
Mailing Address - City:MOBILE
Mailing Address - State:AL
Mailing Address - Zip Code:36603-5827
Mailing Address - Country:US
Mailing Address - Phone:251-690-8158
Mailing Address - Fax:251-544-2188
Practice Address - Street 1:19260 N MOBILE ST
Practice Address - Street 2:
Practice Address - City:CITRONELLE
Practice Address - State:AL
Practice Address - Zip Code:36522-2122
Practice Address - Country:US
Practice Address - Phone:251-866-5585
Practice Address - Fax:251-866-9121
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-05
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL261QP0905X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0905XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, State or Local
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL186546Medicaid
AL630000013Medicaid