1629593314 NPI number — EAGLE ACQUISITION IX LLC

Table of content: SUSAN KAY BURNSIDE P.T. (NPI 1477607471)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629593314 NPI number — EAGLE ACQUISITION IX LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EAGLE ACQUISITION IX 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:
CONCORDIA NURSING AND REHABILITATION - SMITH COUNTY
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:
1629593314
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/21/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
112 HEALTH CARE DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CARTHAGE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37030-1168
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-735-0569
Provider Business Mailing Address Fax Number:
615-735-3210

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
112 HEALTH CARE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CARTHAGE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37030-1168
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-735-0569
Provider Business Practice Location Address Fax Number:
615-735-3210
Provider Enumeration Date:
08/03/2017

Additional Information

Authorized Official

Authorized Official Last Name:
PHILIPSON
Authorized Official First Name:
BENT
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGING MEMBER
Authorized Official Telephone Number:
516-869-3700

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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