=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104956846
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY DEVELOPMENTAL SERVICES, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/06/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 455 HANNINGS LANE
-----------------------------------------------------
City | MARTIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-587-3851
-----------------------------------------------------
Fax | 731-587-0548
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 455 HANNINGS LANE
-----------------------------------------------------
City | MARTIN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38237
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-587-3851
-----------------------------------------------------
Fax | 731-587-0548
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ACCOUNTANT
-----------------------------------------------------
Name | KIM TURNER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 731-587-3851
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------