Provider Demographics
NPI:1972608941
Name:EASTER SEALS ALABAMA, INC. EASTER SEALS WEST ALABAMA
Entity type:Organization
Organization Name:EASTER SEALS ALABAMA, INC. EASTER SEALS WEST ALABAMA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:RONNY
Authorized Official - Middle Name:B
Authorized Official - Last Name:JOHNSTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-759-1211
Mailing Address - Street 1:PO BOX 2817
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35403-2817
Mailing Address - Country:US
Mailing Address - Phone:205-759-1211
Mailing Address - Fax:205-349-1162
Practice Address - Street 1:1110 DR. EDWARD HILLARD DRIVE
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35401-3207
Practice Address - Country:US
Practice Address - Phone:205-759-1211
Practice Address - Fax:205-349-1162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2021-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL12008261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL515-31066OtherBLUE CROSS & BLUE SHIELD
AL51531482OtherBLUE CROSS & BLUE SHIELD
AL010-175OtherBLUE CROSS & BLUE SHIELD
AL529101420Medicaid
AL010-175OtherBCBS OF ALABAMA
AL51077985OtherBLUE CROSS & BLUE SHIELD
AL51515014OtherBLUE CROSS & BLUE SHIELD
AL51533901OtherBLUE CROSS & BLUE SHIELD
AL51515014OtherBLUE CROSS & BLUE SHIELD