Healthcare Provider Details

I. General information

NPI: 1881853117
Provider Name (Legal Business Name): RALEIGH PROFESSIONAL ASSOCIATES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/02/2008
Last Update Date: 06/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960B AUSTIN PEAY HWY
MEMPHIS TN
38128-5602
US

IV. Provider business mailing address

2960B AUSTIN PEAY HWY
MEMPHIS TN
38128-5602
US

V. Phone/Fax

Practice location:
  • Phone: 901-372-7878
  • Fax: 901-373-9298
Mailing address:
  • Phone: 901-372-7878
  • Fax: 901-373-9298

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number0000000035
License Number StateTN

VIII. Authorized Official

Name: MRS. BARBARA KAY DOTY
Title or Position: PROGRAM SPONSOR
Credential:
Phone: 901-372-7878