Provider Demographics
NPI:1770664450
Name:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Entity Type:Organization
Organization Name:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Other - Org Name:TALLADEGA COUNTY HOME CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:STATE HOME CARE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GROVER
Authorized Official - Middle Name:T
Authorized Official - Last Name:WEDGEWORTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-206-5341
Mailing Address - Street 1:201 MONROE ST
Mailing Address - Street 2:THE RSA TOWER, SUITE 1200
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36104-3735
Mailing Address - Country:US
Mailing Address - Phone:334-206-5341
Mailing Address - Fax:334-206-5985
Practice Address - Street 1:311 N ELM AVE
Practice Address - Street 2:
Practice Address - City:SYLACAUGA
Practice Address - State:AL
Practice Address - Zip Code:35150-1992
Practice Address - Country:US
Practice Address - Phone:256-249-4893
Practice Address - Fax:256-208-0886
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF ALABAMA DEPARTMENT OF PUBLIC HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-10-18
Last Update Date:2009-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL01-7861Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER