Provider Demographics
NPI:1215990734
Name:SPECTRACARE HEALTH SYSTEMS, INC.
Entity type:Organization
Organization Name:SPECTRACARE HEALTH SYSTEMS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
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 2:2694 SOUTH PARK AVE.
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 1:134 PREVATT RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36301-5427
Practice Address - Country:US
Practice Address - Phone:334-794-0731
Practice Address - Fax:334-671-9199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-07
Last Update Date:2012-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL331000069Medicaid
AL331000467Medicaid
FL059726100Medicaid
AL330034010Medicaid
AL51003550OtherCOMMERCIAL INSURANCE
AL008412000Medicaid
AL331600592Medicaid
AL591600003Medicaid
AL008301620Medicaid
AL330000010Medicaid
AL33000010Medicaid
AL331000067Medicaid
AL51043903OtherBLUE CROSS BLUE SHIELD
AL590000010Medicaid
AL591500003Medicaid
AL331600587Medicaid
AL331600587Medicaid
AL33000010Medicaid
FL059726100Medicaid
AL008412000Medicaid