Healthcare Provider Details

I. General information

NPI: 1316018286
Provider Name (Legal Business Name): BOLIVAR OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2006
Last Update Date: 04/13/2020
Certification Date: 04/13/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

700 NUCKOLLS RD
BOLIVAR TN
38008-1531
US

IV. Provider business mailing address

7400 NEW LA GRANGE RD SUITE #100
LOUISVILLE KY
40222-4870
US

V. Phone/Fax

Practice location:
  • Phone: 731-658-4707
  • Fax: 731-658-4769
Mailing address:
  • Phone: 502-429-8062
  • Fax: 502-429-0650

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number171
License Number StateTN

VIII. Authorized Official

Name: MR. STACEY PAUL ROGERS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 502-429-8062