Provider Demographics
NPI:1972806867
Name:HAYNEVILLE PODIATRY CLINIC
Entity Type:Organization
Organization Name:HAYNEVILLE PODIATRY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:THERESA
Authorized Official - Middle Name:I
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:334-271-3333
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:HAYNEVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:36040-0190
Mailing Address - Country:US
Mailing Address - Phone:334-548-6440
Mailing Address - Fax:334-548-6441
Practice Address - Street 1:221 HAYNEVILLE PLAZA
Practice Address - Street 2:
Practice Address - City:HAYNEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36040-0190
Practice Address - Country:US
Practice Address - Phone:334-548-6440
Practice Address - Fax:334-548-6441
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-15
Last Update Date:2010-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL134213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty