Provider Demographics
NPI:1609457662
Name:TRACY D ADAMS
Entity Type:Organization
Organization Name:TRACY D ADAMS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:D
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-244-7558
Mailing Address - Street 1:2905 BOB WALLACE AVE SE SUITE B
Mailing Address - Street 2:
Mailing Address - City:HUNTSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35805
Mailing Address - Country:US
Mailing Address - Phone:256-203-2647
Mailing Address - Fax:256-964-8134
Practice Address - Street 1:1290 1ST AVE
Practice Address - Street 2:
Practice Address - City:LAWRENCEBURG
Practice Address - State:TN
Practice Address - Zip Code:38464-2762
Practice Address - Country:US
Practice Address - Phone:931-244-7558
Practice Address - Fax:931-244-7560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-04-20
Last Update Date:2023-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier
Provider Identifiers
StateIdentifier IDID TypeIssuer
14408701OtherCAQH
AL228420Medicaid