Provider Demographics
NPI:1932650769
Name:METHODIST HOME FOR THE AGING
Entity Type:Organization
Organization Name:METHODIST HOME FOR THE AGING
Other - Org Name:FAIR HAVEN ORAL HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:DENTAL DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:LILLIAN
Authorized Official - Middle Name:M
Authorized Official - Last Name:MITCHELL
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:205-951-1473
Mailing Address - Street 1:1424 MONTCLAIR RD
Mailing Address - Street 2:
Mailing Address - City:IRONDALE
Mailing Address - State:AL
Mailing Address - Zip Code:35210-2208
Mailing Address - Country:US
Mailing Address - Phone:205-951-1473
Mailing Address - Fax:
Practice Address - Street 1:1424 MONTCLAIR RD
Practice Address - Street 2:
Practice Address - City:IRONDALE
Practice Address - State:AL
Practice Address - Zip Code:35210-2208
Practice Address - Country:US
Practice Address - Phone:205-951-1473
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-17
Last Update Date:2016-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD0000XAmbulatory Health Care FacilitiesClinic/CenterDental