Provider Demographics
NPI:1891856134
Name:SOUTHEAST ALABAMA RURAL HEALTH ASSOCIATES
Entity Type:Organization
Organization Name:SOUTHEAST ALABAMA RURAL HEALTH ASSOCIATES
Other - Org Name:ENTERPRISE CHILDREN'S CENTER & FAMILY MEDICINE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:A
Authorized Official - Last Name:LITTLE
Authorized Official - Suffix:
Authorized Official - Credentials:MPH
Authorized Official - Phone:334-670-6726
Mailing Address - Street 1:1414 ELBA HWY
Mailing Address - Street 2:
Mailing Address - City:TROY
Mailing Address - State:AL
Mailing Address - Zip Code:36079-6020
Mailing Address - Country:US
Mailing Address - Phone:334-670-6726
Mailing Address - Fax:334-670-6731
Practice Address - Street 1:105 E WATTS ST
Practice Address - Street 2:
Practice Address - City:ENTERPRISE
Practice Address - State:AL
Practice Address - Zip Code:36330-2511
Practice Address - Country:US
Practice Address - Phone:334-393-5437
Practice Address - Fax:334-489-4438
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-12
Last Update Date:2019-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL630006018Medicaid
AL630006018Medicaid