Provider Demographics
NPI:1619489671
Name:SECD CHICKASAW
Entity Type:Organization
Organization Name:SECD CHICKASAW
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:REGIONAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:BRITTANY
Authorized Official - Last Name:MCDONALD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-434-7115
Mailing Address - Street 1:4320 MONTEVALLO RD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN BRK
Mailing Address - State:AL
Mailing Address - Zip Code:35213-2722
Mailing Address - Country:US
Mailing Address - Phone:205-434-7115
Mailing Address - Fax:
Practice Address - Street 1:457 N CRAFT HWY
Practice Address - Street 2:
Practice Address - City:CHICKASAW
Practice Address - State:AL
Practice Address - Zip Code:36611-1364
Practice Address - Country:US
Practice Address - Phone:251-456-8406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-10-31
Last Update Date:2017-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental