Healthcare Provider Details

I. General information

NPI: 1629611637
Provider Name (Legal Business Name): CALICO DEVELOPMENTAL SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2019
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3874 VISCOUNT AVE STE 7
MEMPHIS TN
38118-6000
US

IV. Provider business mailing address

3874 VISCOUNT AVE STE 7
MEMPHIS TN
38118-6000
US

V. Phone/Fax

Practice location:
  • Phone: 615-968-0447
  • Fax: 901-417-8113
Mailing address:
  • Phone: 615-968-0447
  • Fax: 901-417-8113

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: STACEY BUCHANNON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 404-819-1611