Organization
EFC #2
Active
Organization subpart
No
Provider details
NPI number
Authorized official
ROSE L DODGE (OWNER)
(931) 952-3499
Entity
Organization
Contact information
Practice address
603 AMANA AVE., FAYETTEVILLE, TN 37334
(931) 240-0682
(931) 240-0054
Mailing address
603 AMANA AVE., FAYETTEVILLE, TN 37334
(931) 240-0682
(931) 240-0054
Taxonomy
Speciality
Code
Description
License number
State
251S00000X
Community/Behavioral Health Agency
Primary
—
—
320700000X
Physical Disabilities Residential Treatment Facility
—
—
Other
Enumeration date
07/30/2024
Last updated
07/31/2024
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