Provider Demographics
NPI:1982851911
Name:SHELBY RESIDENTIAL & VOCATIONAL SERVICES, INC.
Entity Type:Organization
Organization Name:SHELBY RESIDENTIAL & VOCATIONAL SERVICES, INC.
Other - Org Name:OLD EGYPT CENTRAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:
Authorized Official - Last Name:COOPER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-312-6845
Mailing Address - Street 1:3971 KNIGHT ARNOLD RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-3004
Mailing Address - Country:US
Mailing Address - Phone:901-869-7787
Mailing Address - Fax:901-322-6391
Practice Address - Street 1:3785 OLD EGYPT CENTRAL
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128
Practice Address - Country:US
Practice Address - Phone:901-373-9346
Practice Address - Fax:901-312-9906
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SHELBY RESIDENTIAL & VOCATIONAL SERVICES, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-08-21
Last Update Date:2023-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL323-067-6609315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7447077Medicaid