Provider Demographics
NPI:1871769570
Name:FRED C SANDLIN, JR
Entity type:Organization
Organization Name:FRED C SANDLIN, JR
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FRED
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANDLIN
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:205-921-4267
Mailing Address - Street 1:PO BOX 5047
Mailing Address - Street 2:
Mailing Address - City:MERIDIAN
Mailing Address - State:MS
Mailing Address - Zip Code:39302-5047
Mailing Address - Country:US
Mailing Address - Phone:800-447-4095
Mailing Address - Fax:601-482-7490
Practice Address - Street 1:797 MILITARY ST S
Practice Address - Street 2:
Practice Address - City:HAMILTON
Practice Address - State:AL
Practice Address - Zip Code:35570-4737
Practice Address - Country:US
Practice Address - Phone:205-921-4267
Practice Address - Fax:205-921-2576
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-02
Last Update Date:2008-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL104160332B00000X, 332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
0830870001Medicare NSC