Provider Demographics
NPI:1679994198
Name:CUSTOMIZED MEDICAL NEEDS
Entity type:Organization
Organization Name:CUSTOMIZED MEDICAL NEEDS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTI
Authorized Official - Middle Name:
Authorized Official - Last Name:ALEXANDER-DAVIDSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:866-563-7772
Mailing Address - Street 1:8295 TOURNAMEMT DR
Mailing Address - Street 2:STE 150
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38125-8900
Mailing Address - Country:US
Mailing Address - Phone:866-563-7772
Mailing Address - Fax:901-255-0758
Practice Address - Street 1:8295 TOURNAMENT DR
Practice Address - Street 2:STE 2
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38125-8906
Practice Address - Country:US
Practice Address - Phone:866-563-7772
Practice Address - Fax:901-255-0758
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-12-31
Last Update Date:2013-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN6151932305S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305S00000XManaged Care OrganizationsPoint of Service