Provider Demographics
NPI:1629549068
Name:FORREST AVE MEDICAL CLINIC, LLC
Entity Type:Organization
Organization Name:FORREST AVE MEDICAL CLINIC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JANIE
Authorized Official - Middle Name:T
Authorized Official - Last Name:TESCHNER
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:256-393-3009
Mailing Address - Street 1:1016 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-3540
Mailing Address - Country:US
Mailing Address - Phone:256-549-5002
Mailing Address - Fax:256-549-5003
Practice Address - Street 1:1016 FORREST AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-3540
Practice Address - Country:US
Practice Address - Phone:256-549-5002
Practice Address - Fax:256-549-5003
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-12-11
Last Update Date:2018-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL127451Medicaid