Healthcare Provider Details

I. General information

NPI: 1396213492
Provider Name (Legal Business Name): FOREST AVENUE OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2018
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1116 FOREST AVE
JACKSON MS
39206-3216
US

IV. Provider business mailing address

9020 OVERLOOK BLVD STE 202
BRENTWOOD TN
37027-2755
US

V. Phone/Fax

Practice location:
  • Phone: 601-366-6461
  • Fax: 601-362-4041
Mailing address:
  • Phone: 615-250-7100
  • Fax: 615-250-7101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN THOMAS FICK
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 615-250-7100