1770049504 NPI number — JELLICO TN OPCO LLC

Table of content: (NPI 1770049504)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1770049504 NPI number — JELLICO TN OPCO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
JELLICO TN OPCO 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:
BEECH TREE HEALTH AND REHABILITATION
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:
1770049504
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2071 FLATBUSH AVE STE 12
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
BROOKLYN
Provider Business Mailing Address State Name:
NY
Provider Business Mailing Address Postal Code:
11234-4340
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:
240 HOSPITAL LN
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JELLICO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37762-4401
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-784-6626
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/18/2019

Additional Information

Authorized Official

Authorized Official Last Name:
HERSKOWITZ
Authorized Official First Name:
DAVID
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
212-444-1991

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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