Provider Demographics
NPI:1295286300
Name:MULBERRY MEDICAL, LLC
Entity type:Organization
Organization Name:MULBERRY MEDICAL, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KYNARD
Authorized Official - Middle Name:L
Authorized Official - Last Name:ADAMS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:334-264-3434
Mailing Address - Street 1:2100 CHESTNUT ST
Mailing Address - Street 2:
Mailing Address - City:MONTGOMERY
Mailing Address - State:AL
Mailing Address - Zip Code:36106-1113
Mailing Address - Country:US
Mailing Address - Phone:334-676-4090
Mailing Address - Fax:334-676-4091
Practice Address - Street 1:2100 CHESTNUT ST
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-1113
Practice Address - Country:US
Practice Address - Phone:334-676-4090
Practice Address - Fax:334-676-4091
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-24
Last Update Date:2016-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10658305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service