1194973073 NPI number — GERIATRICARE, LLC

Table of content: (NPI 1194973073)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194973073 NPI number — GERIATRICARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GERIATRICARE, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1194973073
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/03/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
636 DORA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37665-1016
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-677-2222
Provider Business Mailing Address Fax Number:
423-246-1026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3641 MEMORIAL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37664-3422
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-246-2411
Provider Business Practice Location Address Fax Number:
423-246-8997
Provider Enumeration Date:
09/03/2008

Additional Information

Authorized Official

Authorized Official Last Name:
QUILLEN
Authorized Official First Name:
LINDA
Authorized Official Middle Name:
S
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
423-677-2222

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  APN6094 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3902189 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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