Provider Demographics
NPI:1417128968
Name:THE MICHAL CHILD DEVELOPMENT CENTER
Entity Type:Organization
Organization Name:THE MICHAL CHILD DEVELOPMENT CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MISS
Authorized Official - First Name:MARY
Authorized Official - Middle Name:L
Authorized Official - Last Name:MICHAL
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-928-9007
Mailing Address - Street 1:302 WESLEY ST STE 10
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-1769
Mailing Address - Country:US
Mailing Address - Phone:423-928-9007
Mailing Address - Fax:423-928-9249
Practice Address - Street 1:302 WESLEY ST STE 10
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601-1769
Practice Address - Country:US
Practice Address - Phone:423-928-9007
Practice Address - Fax:423-928-9249
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-12
Last Update Date:2008-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD3984174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6906086Medicaid
TN1275534810OtherNPI
TNBO3200Medicare UPIN