Provider Demographics
NPI:1689651408
Name:MONTGOMERY AIDS OUTREACH, INC.
Entity Type:Organization
Organization Name:MONTGOMERY AIDS OUTREACH, INC.
Other - Org Name:COPELAND CARE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:ANNE
Authorized Official - Middle Name:
Authorized Official - Last Name:JORDAN-REYNOLDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-386-0853
Mailing Address - Street 1:PO BOX 11087
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36111-0087
Mailing Address - Country:US
Mailing Address - Phone:334-280-3349
Mailing Address - Fax:334-356-1426
Practice Address - Street 1:2900 MCGEHEE RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36111
Practice Address - Country:US
Practice Address - Phone:334-280-3349
Practice Address - Fax:334-356-1426
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-22
Last Update Date:2022-11-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALL5111 TYPE R261QM2500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529401770Medicaid