Provider Demographics
NPI:1821504598
Name:CHARLES D. RUBLEY DBA BEAVERTON MEDICAL CLINIC
Entity Type:Organization
Organization Name:CHARLES D. RUBLEY DBA BEAVERTON MEDICAL CLINIC
Other - Org Name:CHARLES D. RUBLEY DBA BEAVERTON MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER / PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:D
Authorized Official - Last Name:RUBLEY
Authorized Official - Suffix:
Authorized Official - Credentials:CRNP
Authorized Official - Phone:205-606-1200
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:AL
Mailing Address - Zip Code:35544-0038
Mailing Address - Country:US
Mailing Address - Phone:205-606-1200
Mailing Address - Fax:205-606-1202
Practice Address - Street 1:12815 US HWY 278
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:AL
Practice Address - Zip Code:35544
Practice Address - Country:US
Practice Address - Phone:205-606-1200
Practice Address - Fax:205-606-1202
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-12-18
Last Update Date:2018-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-081378363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty