Provider Demographics
NPI:1740493436
Name:CENTERS FOR DEVELOPMENTALLY DISABLED, NORTH CENTRAL AL
Entity type:Organization
Organization Name:CENTERS FOR DEVELOPMENTALLY DISABLED, NORTH CENTRAL AL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:COMPTROLLER
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAYLA
Authorized Official - Middle Name:SHA-VON
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:256-350-1458
Mailing Address - Street 1:PO BOX 2091
Mailing Address - Street 2:1602 CHURCH ST SE;
Mailing Address - City:DECATUR
Mailing Address - State:AL
Mailing Address - Zip Code:35601-3402
Mailing Address - Country:US
Mailing Address - Phone:256-350-1458
Mailing Address - Fax:256-350-1485
Practice Address - Street 1:1602 CHURCH ST SE
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:AL
Practice Address - Zip Code:35601-3402
Practice Address - Country:US
Practice Address - Phone:256-350-1458
Practice Address - Fax:256-350-1485
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-08
Last Update Date:2015-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-037625363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL529932620Medicaid