Provider Demographics
NPI:1548809403
Name:MIZELL MEMORIAL HOSPITAL, INC.
Entity type:Organization
Organization Name:MIZELL MEMORIAL HOSPITAL, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO / CFO
Authorized Official - Prefix:
Authorized Official - First Name:JANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WYATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-493-9111
Mailing Address - Street 1:PO BOX 1010
Mailing Address - Street 2:
Mailing Address - City:OPP
Mailing Address - State:AL
Mailing Address - Zip Code:36467-1010
Mailing Address - Country:US
Mailing Address - Phone:334-493-3541
Mailing Address - Fax:
Practice Address - Street 1:103 E MEMORIAL AVE STE A
Practice Address - Street 2:
Practice Address - City:OPP
Practice Address - State:AL
Practice Address - Zip Code:36467-1746
Practice Address - Country:US
Practice Address - Phone:334-493-5555
Practice Address - Fax:334-493-0517
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-12-24
Last Update Date:2021-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Multi-Specialty
No261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Multi-Specialty