Provider Demographics
NPI:1760419717
Name:BLEDSOE TATE OF PRINCETON, LLC
Entity Type:Organization
Organization Name:BLEDSOE TATE OF PRINCETON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER RELATIONS COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:
Authorized Official - Last Name:RICHARDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-396-1400
Mailing Address - Street 1:7088 UNIVERSITY CT
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36117-6992
Mailing Address - Country:US
Mailing Address - Phone:334-396-1400
Mailing Address - Fax:334-396-2727
Practice Address - Street 1:924 FULTON AVENUE
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35211
Practice Address - Country:US
Practice Address - Phone:205-780-6333
Practice Address - Fax:205-780-6008
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-26
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL=========OtherFEDERAL TAX ID #