Provider Demographics
NPI:1972981918
Name:TBD
Entity Type:Organization
Organization Name:TBD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PHYSICAL THERAPIST
Authorized Official - Prefix:
Authorized Official - First Name:BRET
Authorized Official - Middle Name:
Authorized Official - Last Name:STACY
Authorized Official - Suffix:
Authorized Official - Credentials:PT
Authorized Official - Phone:205-259-3991
Mailing Address - Street 1:76359 AL HIGHWAY 77
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:AL
Mailing Address - Zip Code:35096
Mailing Address - Country:US
Mailing Address - Phone:205-259-3991
Mailing Address - Fax:205-683-2468
Practice Address - Street 1:76359 AL HIGHWAY 77
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:AL
Practice Address - Zip Code:35096-5039
Practice Address - Country:US
Practice Address - Phone:205-259-3991
Practice Address - Fax:205-683-2468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-11
Last Update Date:2015-10-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALPTH7544225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty