Provider Demographics
NPI:1194943514
Name:SHELBY RESIDENTIAL AND VOCATIONAL SERVICES
Entity type:Organization
Organization Name:SHELBY RESIDENTIAL AND VOCATIONAL SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:SHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:DURBIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-821-1067
Mailing Address - Street 1:3971 KNIGHT ARNOLD RD
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38118-3004
Mailing Address - Country:US
Mailing Address - Phone:901-869-7787
Mailing Address - Fax:
Practice Address - Street 1:3971 KNIGHT ARNOLD RD
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38118-3004
Practice Address - Country:US
Practice Address - Phone:901-869-7787
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-23
Last Update Date:2024-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL323-066-6232315P00000X
TNL323-066-6234315P00000X
TNL323-066-6235315P00000X
TNL323-066-6236315P00000X
TNL323-066-6237315P00000X
TNL323-066-6238315P00000X
TNL323-066-6239315P00000X
TNL323-066-6244315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7447075Medicaid
TN7447076Medicaid
TN7447078Medicaid
TN7447077Medicaid
TN7447080Medicaid
TN7447079Medicaid
TN7447081Medicaid
TN7447082Medicaid