Healthcare Provider Details

I. General information

NPI: 1174184709
Provider Name (Legal Business Name): DARSALUD COMMUNITY CENTER INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/25/2019
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6063 MOUNT MORIAH ROAD EXT STE 4
MEMPHIS TN
38115-2665
US

IV. Provider business mailing address

6625 LENOX PARK DR STE 202
MEMPHIS TN
38115-8200
US

V. Phone/Fax

Practice location:
  • Phone: 901-531-8800
  • Fax: 901-531-8801
Mailing address:
  • Phone: 901-922-5951
  • Fax: 901-922-5952

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number
License Number State

VIII. Authorized Official

Name: ANDREA LAJUANA IVORY FULLER
Title or Position: BILLING AND CREDENTIALING MANAGER
Credential: MAML, CPC
Phone: 901-922-5951