Provider Demographics
NPI:1174184709
Name:DARSALUD COMMUNITY CENTER INC
Entity Type:Organization
Organization Name:DARSALUD COMMUNITY CENTER INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:BILLING AND CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANDREA
Authorized Official - Middle Name:LAJUANA
Authorized Official - Last Name:IVORY FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:MAML, CPC
Authorized Official - Phone:901-922-5951
Mailing Address - Street 1:6074 APPLE TREE DR STE 10
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38115-0300
Mailing Address - Country:US
Mailing Address - Phone:901-922-5951
Mailing Address - Fax:
Practice Address - Street 1:6063 MOUNT MORIAH ROAD EXT STE 4
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38115-2665
Practice Address - Country:US
Practice Address - Phone:901-531-8800
Practice Address - Fax:901-531-8801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-06-25
Last Update Date:2023-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ051384Medicaid