=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255036174
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | AT HOME ADULT DAY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2023
-----------------------------------------------------
Last Update Date | 03/31/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1684 HUNTGATE CV
-----------------------------------------------------
City | CORDOVA
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38016-1429
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-501-1005
-----------------------------------------------------
Fax | 901-753-1513
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3499 RIVERDALE RD
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38115-4400
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-652-5647
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MARILYN HULBERT
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 901-652-5647
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QA0600X
-----------------------------------------------------
Taxonomy Name | Adult Day Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------