Provider Demographics
NPI:1316678592
Name:SRD MUSCLE SHOALS PLLC
Entity type:Organization
Organization Name:SRD MUSCLE SHOALS PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTYN
Authorized Official - Middle Name:
Authorized Official - Last Name:SHIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-320-5903
Mailing Address - Street 1:PO BOX 740979
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-7423
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2402 AVALON AVE STE A
Practice Address - Street 2:
Practice Address - City:MUSCLE SHOALS
Practice Address - State:AL
Practice Address - Zip Code:35661-3286
Practice Address - Country:US
Practice Address - Phone:256-383-1112
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-06-20
Last Update Date:2022-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1223G0001XDental ProvidersDentistGeneral PracticeGroup - Single Specialty