Provider Demographics
NPI:1952855017
Name:MDC HOLDING ENTERPRISE
Entity Type:Organization
Organization Name:MDC HOLDING ENTERPRISE
Other - Org Name:FAMILY CARE ON FORREST AVENUE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MELANIE
Authorized Official - Middle Name:DIANNE
Authorized Official - Last Name:KILGO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-490-7333
Mailing Address - Street 1:1039 FORREST AVE
Mailing Address - Street 2:
Mailing Address - City:GADSDEN
Mailing Address - State:AL
Mailing Address - Zip Code:35901-3539
Mailing Address - Country:US
Mailing Address - Phone:256-543-7406
Mailing Address - Fax:
Practice Address - Street 1:1039 FORREST AVE
Practice Address - Street 2:
Practice Address - City:GADSDEN
Practice Address - State:AL
Practice Address - Zip Code:35901-3539
Practice Address - Country:US
Practice Address - Phone:256-543-7406
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-06
Last Update Date:2016-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL102I506781261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL102I506781Medicare UPIN