Provider Demographics
NPI:1902931314
Name:MADISON HAYWOOD COUNTY DEVELOPMENTAL SERVICES, INC
Entity Type:Organization
Organization Name:MADISON HAYWOOD COUNTY DEVELOPMENTAL SERVICES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:QA MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TOMIKA
Authorized Official - Middle Name:
Authorized Official - Last Name:BARBOUR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-664-0855
Mailing Address - Street 1:PO BOX 11205
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38308-0120
Mailing Address - Country:US
Mailing Address - Phone:731-664-0855
Mailing Address - Fax:731-668-2433
Practice Address - Street 1:38 GARLAND DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-3602
Practice Address - Country:US
Practice Address - Phone:731-664-0855
Practice Address - Fax:731-668-2433
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6292251C00000X
TN6295251C00000X
TN6297251C00000X
TN6293251C00000X
TN6294251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN00068OtherDMRS PROVIDER NUMBER