Provider Demographics
NPI:1922170109
Name:DOTHAN HOUSTON COUNTY MENTAL RETARDATION BOARD, INC.
Entity Type:Organization
Organization Name:DOTHAN HOUSTON COUNTY MENTAL RETARDATION BOARD, INC.
Other - Org Name:VAUGHN BLUMBERG SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ED
Authorized Official - Middle Name:
Authorized Official - Last Name:DORSEY
Authorized Official - Suffix:
Authorized Official - Credentials:BS
Authorized Official - Phone:334-793-3102
Mailing Address - Street 1:2715 FLYNN RD
Mailing Address - Street 2:
Mailing Address - City:DOTHAN
Mailing Address - State:AL
Mailing Address - Zip Code:36303-1162
Mailing Address - Country:US
Mailing Address - Phone:334-793-3102
Mailing Address - Fax:334-793-7740
Practice Address - Street 1:2715 FLYNN RD
Practice Address - Street 2:
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36303-1162
Practice Address - Country:US
Practice Address - Phone:334-793-3102
Practice Address - Fax:334-793-7740
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL251B00000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services