Provider Demographics
NPI:1457525446
Name:KNOXVILLE INTEGRATED DEVELOPMENTAL SERVICES, INC.
Entity Type:Organization
Organization Name:KNOXVILLE INTEGRATED DEVELOPMENTAL SERVICES, INC.
Other - Org Name:KIDS REHAB
Other - Org Type:Other Name
Authorized Official - Title/Position:HR/IT MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:RODGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-539-1928
Mailing Address - Street 1:9047 EXECUTIVE PARK DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37923-4605
Mailing Address - Country:US
Mailing Address - Phone:865-539-1928
Mailing Address - Fax:865-539-6461
Practice Address - Street 1:9047 EXECUTIVE PARK DR
Practice Address - Street 2:SUITE 115
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37923-4605
Practice Address - Country:US
Practice Address - Phone:865-539-1928
Practice Address - Fax:865-539-6461
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-22
Last Update Date:2009-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4177096OtherBCBS