Healthcare Provider Details

I. General information

NPI: 1003950692
Provider Name (Legal Business Name): MICHAEL DUNN CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2007
Last Update Date: 10/27/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 VILLAGE TRCE
KINGSTON TN
37763-7066
US

IV. Provider business mailing address

629 GALLAHER RD
KINGSTON TN
37763-4215
US

V. Phone/Fax

Practice location:
  • Phone: 865-376-3416
  • Fax: 865-717-4858
Mailing address:
  • Phone: 865-376-3416
  • Fax: 865-717-4858

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code315P00000X
TaxonomyIntellectual Disabilities Intermediate Care Facility
License NumberL 323-056-1347
License Number StateTN

VIII. Authorized Official

Name: MS. TRACEY TAYLOR
Title or Position: RESIDENTIAL ACCOUNTANT
Credential:
Phone: 865-376-3416