Provider Demographics
NPI:1801161138
Name:DR KEITH DISMUKES L.L.C.
Entity type:Organization
Organization Name:DR KEITH DISMUKES L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASST. OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:LAURI
Authorized Official - Middle Name:ANNE
Authorized Official - Last Name:CAMERON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:334-287-2584
Mailing Address - Street 1:PO BOX 650
Mailing Address - Street 2:P.O. BOX 650
Mailing Address - City:DEMOPOLIS
Mailing Address - State:AL
Mailing Address - Zip Code:36732-0650
Mailing Address - Country:US
Mailing Address - Phone:334-289-0499
Mailing Address - Fax:334-289-3013
Practice Address - Street 1:202 US HIGHWAY 80 E
Practice Address - Street 2:
Practice Address - City:DEMOPOLIS
Practice Address - State:AL
Practice Address - Zip Code:36732-3622
Practice Address - Country:US
Practice Address - Phone:334-289-0499
Practice Address - Fax:334-289-3013
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-20
Last Update Date:2012-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALAD7121724261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care