| Organization Name: | MTN LAKE UROLOGY PC |
| NPI Number: | 1801050364 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | JENNIFER SIMMONS (OFFICE MANAGER) |
| Mailing Address: | 304 Parks Ave Scottsboro |
| State: | AL US |
| Postal Code: | 357682412 |
| Phone Number: | 2562598765 |
| Fax Number: | |
| NPI Enumeration Date: | 07/14/2008 |
| NPI Last Update Date: | 11/13/2012 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 174400000X |
| License Number: | 17993 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | AL |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Specialist |
| Taxonomy Specialization: | |
| Taxonomy Definition: | An individual educated and trained in an applied knowledge discipline used in the performance of work at a level requiring knowledge and skills beyond or apart from that provided by a general education or liberal arts degree. |