Provider Demographics
NPI:1609182450
Name:MODERN DAY LIVING CERIFIED RESIDENTIAL FACILITY
Entity Type:Organization
Organization Name:MODERN DAY LIVING CERIFIED RESIDENTIAL FACILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARETHA
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:BUFFER
Authorized Official - Suffix:
Authorized Official - Credentials:NURSE
Authorized Official - Phone:205-792-2891
Mailing Address - Street 1:10761 OLD GREENSBORO RD
Mailing Address - Street 2:
Mailing Address - City:TUSCALOOSA
Mailing Address - State:AL
Mailing Address - Zip Code:35405-9185
Mailing Address - Country:US
Mailing Address - Phone:205-792-2891
Mailing Address - Fax:205-342-1431
Practice Address - Street 1:10761 OLD GREENSBORO RD
Practice Address - Street 2:
Practice Address - City:TUSCALOOSA
Practice Address - State:AL
Practice Address - Zip Code:35405-9185
Practice Address - Country:US
Practice Address - Phone:205-792-2891
Practice Address - Fax:205-342-1431
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-08-30
Last Update Date:2010-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL320900000X320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities