Provider Demographics
NPI:1578022117
Name:RESILIENT SPREAD DEVELOPMENT
Entity Type:Organization
Organization Name:RESILIENT SPREAD DEVELOPMENT
Other - Org Name:GREAT PERSONAL CARE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:ROBERTA
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-475-6165
Mailing Address - Street 1:4315 13TH AVE
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37407-3104
Mailing Address - Country:US
Mailing Address - Phone:423-475-6165
Mailing Address - Fax:
Practice Address - Street 1:4315 13TH AVE
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37407-3104
Practice Address - Country:US
Practice Address - Phone:423-475-6165
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-13
Last Update Date:2019-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness