Healthcare Provider Details

I. General information

NPI: 1619253853
Provider Name (Legal Business Name): CHILDREN'S HOME CHAMBLISS SHELTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/02/2011
Last Update Date: 11/02/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

315 GILLESPIE RD
CHATTANOOGA TN
37411-3105
US

IV. Provider business mailing address

315 GILLESPIE RD
CHATTANOOGA TN
37411-3105
US

V. Phone/Fax

Practice location:
  • Phone: 423-698-2456
  • Fax: 423-242-1670
Mailing address:
  • Phone: 423-698-2456
  • Fax: 423-242-1670

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License NumberSO/10864A
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberSO/10864A
License Number StateTN

VIII. Authorized Official

Name: MR. PHILIP A ACORD SR.
Title or Position: PRESIDENT/CEO
Credential:
Phone: 423-698-2456