Provider Demographics
NPI:1487274650
Name:FAITH MEDICAL CLINIC LLC
Entity type:Organization
Organization Name:FAITH MEDICAL CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANGELA
Authorized Official - Middle Name:
Authorized Official - Last Name:REYNOSO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-638-4411
Mailing Address - Street 1:64 MCCURDY AVE N
Mailing Address - Street 2:
Mailing Address - City:RAINSVILLE
Mailing Address - State:AL
Mailing Address - Zip Code:35986-4465
Mailing Address - Country:US
Mailing Address - Phone:256-638-4411
Mailing Address - Fax:256-638-9275
Practice Address - Street 1:64 MCCURDY AVE N
Practice Address - Street 2:
Practice Address - City:RAINSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35986-4465
Practice Address - Country:US
Practice Address - Phone:256-638-4411
Practice Address - Fax:256-638-9275
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-04-17
Last Update Date:2025-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL1912470824Medicaid