Provider Demographics
NPI:1417091042
Name:LADY IN LACE
Entity type:Organization
Organization Name:LADY IN LACE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:FAYE
Authorized Official - Middle Name:
Authorized Official - Last Name:GROW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-349-5223
Mailing Address - Street 1:410 QUEEN CITY AVE
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35401-1552
Mailing Address - Country:US
Mailing Address - Phone:205-349-5223
Mailing Address - Fax:205-349-5217
Practice Address - Street 1:410 QUEEN CITY AVE
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-1552
Practice Address - Country:US
Practice Address - Phone:205-349-5223
Practice Address - Fax:205-349-5217
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-16
Last Update Date:2008-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3548461744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case ManagementGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL56040OtherBLUE CROSS BLUE SHIELD
AL009902435Medicaid
0696630001Medicare NSC