1982876454 NPI number — OCOEE FOUNDATION-CC LLC

Table of content: MS. MARY N CAMARATA M.S., CCC-SLP (NPI 1407296494)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982876454 NPI number — OCOEE FOUNDATION-CC LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OCOEE FOUNDATION-CC 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:
WOODBURY NURSING AND REHABILITATION CENTER
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:
1982876454
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/05/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
119 W HIGH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WOODBURY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37190-1226
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-563-5930
Provider Business Mailing Address Fax Number:
615-563-4043

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
119 W HIGH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WOODBURY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37190-1226
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
615-563-5930
Provider Business Practice Location Address Fax Number:
615-563-4043
Provider Enumeration Date:
03/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
HOLCOMBE
Authorized Official First Name:
MICHELLE
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
423-834-3188

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  102 , 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: 0445435 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 7440221 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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