Healthcare Provider Details

I. General information

NPI: 1528897451
Provider Name (Legal Business Name): EFC #2
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/30/2024
Last Update Date: 07/31/2024
Certification Date: 07/31/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

603 AMANA AVE.
FAYETTEVILLE TN
37334
US

IV. Provider business mailing address

603 AMANA AVE.
FAYETTEVILLE TN
37334
US

V. Phone/Fax

Practice location:
  • Phone: 931-240-0682
  • Fax: 931-240-0054
Mailing address:
  • Phone: 931-240-0682
  • Fax: 931-240-0054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: ROSE L DODGE
Title or Position: OWNER
Credential:
Phone: 931-952-3499