Provider Demographics
NPI:1265705065
Name:CLOVERDALE ROAD FAMILY MEDICAL CENTER
Entity type:Organization
Organization Name:CLOVERDALE ROAD FAMILY MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:CAROLYN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEONARD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-386-4673
Mailing Address - Street 1:PO BOX 895
Mailing Address - Street 2:
Mailing Address - City:SHEFFIELD
Mailing Address - State:AL
Mailing Address - Zip Code:35660-0895
Mailing Address - Country:US
Mailing Address - Phone:256-764-1263
Mailing Address - Fax:256-764-9611
Practice Address - Street 1:3502 CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AL
Practice Address - Zip Code:35633-1302
Practice Address - Country:US
Practice Address - Phone:256-764-1263
Practice Address - Fax:256-764-9611
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-10
Last Update Date:2012-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL8871207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty