Provider Demographics
NPI:1205385176
Name:SPECTRACARE INTEGRATED SERVICES LLC
Entity type:Organization
Organization Name:SPECTRACARE INTEGRATED SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECTUTIVE OFFICER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MELISSA
Authorized Official - Middle Name:
Authorized Official - Last Name:KIRKLAND
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-712-2720
Mailing Address - Street 1:PO BOX 1245
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36302-1245
Mailing Address - Country:US
Mailing Address - Phone:334-712-2720
Mailing Address - Fax:334-712-2727
Practice Address - Street 1:3542 MONTGOMERY HWY
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-2165
Practice Address - Country:US
Practice Address - Phone:334-712-2720
Practice Address - Fax:334-712-2727
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SPECTRACARE HEALTH SYSTEMS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2016-10-03
Last Update Date:2016-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)