Provider Demographics
NPI:1669830881
Name:MEDEXPRESS LITTLEVILLE LLC
Entity Type:Organization
Organization Name:MEDEXPRESS LITTLEVILLE LLC
Other - Org Name:MEDEXPRESS LITTLEVILLE
Other - Org Type:Other Name
Authorized Official - Title/Position:EXECUTIVE DIRECTOR, REVENUE CYCLE
Authorized Official - Prefix:
Authorized Official - First Name:VINCENT
Authorized Official - Middle Name:
Authorized Official - Last Name:BONETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-265-9641
Mailing Address - Street 1:1369A GEORGE WALLACE HWY
Mailing Address - Street 2:
Mailing Address - City:RUSSELLVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35654-3281
Mailing Address - Country:US
Mailing Address - Phone:256-331-9700
Mailing Address - Fax:256-331-2615
Practice Address - Street 1:1369A GEORGE WALLACE HWY
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AL
Practice Address - Zip Code:35654-3281
Practice Address - Country:US
Practice Address - Phone:256-331-9700
Practice Address - Fax:256-331-2615
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HH HEALTH SYSTEM - SHOALS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-02-02
Last Update Date:2016-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALB1705261QR1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL169067Medicaid
AL169067Medicaid