1700762572 NPI number — FAIRFIELD GLADE OF TENNESSEE, LLC

Table of content: (NPI 1700762572)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1700762572 NPI number — FAIRFIELD GLADE OF TENNESSEE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAIRFIELD GLADE OF TENNESSEE, 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:
1700762572
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/19/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2334 41ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WILMINGTON
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28403-5502
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
100 SAMARITAN WAY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CROSSVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38558-1401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-710-0908
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/15/2025

Additional Information

Authorized Official

Authorized Official Last Name:
PURVIS
Authorized Official First Name:
WILLIAM
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT, LIBERTY LIVING MANAGEMEN
Authorized Official Telephone Number:
910-815-3122

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)





Copyright © 2007-2025 www.npivalidator.com