Provider Demographics
NPI:1053029116
Name:SRD ATHENS, PLLC
Entity type:Organization
Organization Name:SRD ATHENS, 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 1:110 E 5TH ST
Mailing Address - Street 2:
Mailing Address - City:TUSCUMBIA
Mailing Address - State:AL
Mailing Address - Zip Code:35674-2410
Mailing Address - Country:US
Mailing Address - Phone:256-383-4990
Mailing Address - Fax:265-383-2182
Practice Address - Street 1:22026 GATEWAY BLVD
Practice Address - Street 2:SUITES A
Practice Address - City:ATHENS
Practice Address - State:AL
Practice Address - Zip Code:35613
Practice Address - Country:US
Practice Address - Phone:256-383-8037
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-08
Last Update Date:2022-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes122300000XDental ProvidersDentistGroup - Multi-Specialty