Provider Demographics
NPI:1710642699
Name:KDDS LLC
Entity Type:Organization
Organization Name:KDDS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:KATRINA
Authorized Official - Middle Name:D
Authorized Official - Last Name:BROUGHTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-481-1685
Mailing Address - Street 1:PO BOX 22
Mailing Address - Street 2:
Mailing Address - City:LA VERGNE
Mailing Address - State:TN
Mailing Address - Zip Code:37086-0022
Mailing Address - Country:US
Mailing Address - Phone:615-481-1685
Mailing Address - Fax:
Practice Address - Street 1:410 RIDGETOP DR
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167-5109
Practice Address - Country:US
Practice Address - Phone:615-481-1685
Practice Address - Fax:615-223-7190
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-11-04
Last Update Date:2022-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility