1629258546 NPI number — CORDOVA HEALTHCARE, LLC

Table of content: (NPI 1629258546)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629258546 NPI number — CORDOVA HEALTHCARE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CORDOVA HEALTHCARE, 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:
GRACE HEALTHCARE OF CORDOVA
Provider Other Organization Name Type Code:
3
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:
1629258546
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/30/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
955 N GERMANTOWN PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CORDOVA
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
38018-6215
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
901-754-1393
Provider Business Mailing Address Fax Number:
336-433-7468

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
955 N GERMANTOWN PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CORDOVA
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38018-6215
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
901-754-1393
Provider Business Practice Location Address Fax Number:
336-433-7468
Provider Enumeration Date:
11/08/2007

Additional Information

Authorized Official

Authorized Official Last Name:
TAYLOR
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
D.
Authorized Official Title or Position:
CHIEF MANAGER
Authorized Official Telephone Number:
423-308-1845

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  0000000238 , 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: 0445218 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7440486 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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