Provider Demographics
NPI:1578089439
Name:INDEV SUPPORTED LIVING LLC.
Entity Type:Organization
Organization Name:INDEV SUPPORTED LIVING LLC.
Other - Org Name:ACA COMMUNITIES LLC.
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RICARDO
Authorized Official - Middle Name:
Authorized Official - Last Name:HEROS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-682-2022
Mailing Address - Street 1:2675 UNION AVENUE EXT
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38112-4401
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2675 UNION AVENUE EXT
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38112-4401
Practice Address - Country:US
Practice Address - Phone:901-682-2022
Practice Address - Fax:901-682-2052
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-22
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN00F91Medicaid