Provider Demographics
NPI:1053416636
Name:DALE COUNTY MENTAL RETARDATION BOARD
Entity type:Organization
Organization Name:DALE COUNTY MENTAL RETARDATION BOARD
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:HERMAN
Authorized Official - Middle Name:F
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:334-774-5132
Mailing Address - Street 1:2047 STUART TARTER RD
Mailing Address - Street 2:
Mailing Address - City:OZARK
Mailing Address - State:AL
Mailing Address - Zip Code:36360-7557
Mailing Address - Country:US
Mailing Address - Phone:334-774-5132
Mailing Address - Fax:334-774-3436
Practice Address - Street 1:2047 STUART TARTER RD
Practice Address - Street 2:
Practice Address - City:OZARK
Practice Address - State:AL
Practice Address - Zip Code:36360-7557
Practice Address - Country:US
Practice Address - Phone:334-774-5132
Practice Address - Fax:334-774-3436
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL251B00000X251B00000X
AL251C00000X251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered251B00000XAgenciesCase Management
Not Answered251C00000XAgenciesDay Training, Developmentally Disabled Services