Provider Demographics
NPI:1841219896
Name:PRIVATE DUTY NURSING SERVICE, INX
Entity Type:Organization
Organization Name:PRIVATE DUTY NURSING SERVICE, INX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:NITA
Authorized Official - Middle Name:F
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-355-1811
Mailing Address - Street 1:1530 WOLVERINE DR SE
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-4949
Mailing Address - Country:US
Mailing Address - Phone:256-355-1811
Mailing Address - Fax:256-355-8419
Practice Address - Street 1:1530 WOLVERINE DR SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-4949
Practice Address - Country:US
Practice Address - Phone:256-355-1811
Practice Address - Fax:256-355-8419
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-19
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL04825251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL510-34325OtherBLUE CROSS BLUE SHIELD
ALPVT0069ZMedicaid
AL510-34325OtherGALLAGER-BASSETT
ALPVT0063ZMedicaid
AL510-34325OtherPARADIGM HEALTH
AL510-34325OtherAETNA