Healthcare Provider Details

I. General information

NPI: 1497807119
Provider Name (Legal Business Name): CROCKETT COUNTY NURSING HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2007
Last Update Date: 06/23/2020
Certification Date: 06/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

580 WEST MAIN STREET
ALAMO TN
38001-0367
US

IV. Provider business mailing address

PO BOX 367
ALAMO TN
38001-0367
US

V. Phone/Fax

Practice location:
  • Phone: 731-696-4541
  • Fax: 731-696-4948
Mailing address:
  • Phone: 731-696-4541
  • Fax: 731-696-4948

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0000000029
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. BARBARA PARK
Title or Position: ADMINISTRATOR
Credential:
Phone: 731-696-4541