1497405328 NPI number — DAC OF SHELBY, LLC

Table of content: (NPI 1497405328)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497405328 NPI number — DAC OF SHELBY, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAC OF SHELBY, 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:
6
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:
1497405328
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1621 GALLERIA BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BRENTWOOD
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37027-2926
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
615-550-9400
Provider Business Mailing Address Fax Number:
615-620-7875

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1108 CHURCH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SHELBY
Provider Business Practice Location Address State Name:
MS
Provider Business Practice Location Address Postal Code:
38774-2200
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
662-846-2590
Provider Business Practice Location Address Fax Number:
662-398-7766
Provider Enumeration Date:
03/24/2022

Additional Information

Authorized Official

Authorized Official Last Name:
WEISHAAR
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
J.
Authorized Official Title or Position:
CHIEF FINANCIAL OFFICER
Authorized Official Telephone Number:
615-550-9459

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)

  • Identifier: 25-5293 . This is a "MEDICARE - SNF" identifier , issued by the state of ( MS ) . This identifiers is of the category "OTHER".




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