=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891145678
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | COMMUNITY DEVELOPMENT CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/13/2016
-----------------------------------------------------
Last Update Date | 11/06/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 JASON MAXWELL BLVD
-----------------------------------------------------
City | LEWISBURG
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37091-2018
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-359-1197
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 113 EAGLETTE WAY
-----------------------------------------------------
City | SHELBYVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37160-9263
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-684-8681
-----------------------------------------------------
Fax | 931-684-9431
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | BUSINESS MANAGER
-----------------------------------------------------
Name | MR. ROBERT JACOBI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 931-684-8681
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 106S00000X
-----------------------------------------------------
Taxonomy Name | Behavior Technician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 103K00000X
-----------------------------------------------------
Taxonomy Name | Behavior Analyst
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------