Provider Demographics
NPI:1922044494
Name:LISTER HEALTH CARE CORPORATION
Entity Type:Organization
Organization Name:LISTER HEALTH CARE CORPORATION
Other - Org Name:ARDMORE CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CREDENTIALING AGENT
Authorized Official - Prefix:
Authorized Official - First Name:KRISTA
Authorized Official - Middle Name:
Authorized Official - Last Name:CHASE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-767-7494
Mailing Address - Street 1:PO BOX 298
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AL
Mailing Address - Zip Code:35631-0298
Mailing Address - Country:US
Mailing Address - Phone:256-767-7494
Mailing Address - Fax:256-760-8432
Practice Address - Street 1:30320 AL HIGHWAY 53 STE B&C
Practice Address - Street 2:
Practice Address - City:ARDMORE
Practice Address - State:AL
Practice Address - Zip Code:35739-8766
Practice Address - Country:US
Practice Address - Phone:256-423-4800
Practice Address - Fax:256-423-8448
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-21
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
ALI067Medicare ID - Type Unspecified