Provider Demographics
NPI:1447389572
Name:MICHAEL DUNN CENTER
Entity Type:Organization
Organization Name:MICHAEL DUNN CENTER
Other - Org Name:MDC LEDA HERRON HOME
Other - Org Type:Other Name
Authorized Official - Title/Position:RESIDENTIAL ACCOUNTANT
Authorized Official - Prefix:
Authorized Official - First Name:TRACEY
Authorized Official - Middle Name:
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-376-3416
Mailing Address - Street 1:629 GALLAHER RD
Mailing Address - Street 2:
Mailing Address - City:KINGSTON
Mailing Address - State:TN
Mailing Address - Zip Code:37763-4215
Mailing Address - Country:US
Mailing Address - Phone:865-376-3416
Mailing Address - Fax:865-717-4858
Practice Address - Street 1:104 VILLAGE TRCE
Practice Address - Street 2:
Practice Address - City:KINGSTON
Practice Address - State:TN
Practice Address - Zip Code:37763-7066
Practice Address - Country:US
Practice Address - Phone:865-376-3416
Practice Address - Fax:865-717-4858
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-05
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL 323-056-1349315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7447112Medicaid