Healthcare Provider Details

I. General information

NPI: 1053416636
Provider Name (Legal Business Name): DALE COUNTY MENTAL RETARDATION BOARD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/14/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2047 STUART TARTER RD
OZARK AL
36360-7557
US

IV. Provider business mailing address

2047 STUART TARTER RD
OZARK AL
36360-7557
US

V. Phone/Fax

Practice location:
  • Phone: 334-774-5132
  • Fax: 334-774-3436
Mailing address:
  • Phone: 334-774-5132
  • Fax: 334-774-3436

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number251B00000X
License Number StateAL
# 2
Primary TaxonomyN
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number251C00000X
License Number StateAL

VIII. Authorized Official

Name: MR. HERMAN F. JACKSON
Title or Position: DIRECTOR
Credential:
Phone: 334-774-5132