Healthcare Provider Details

I. General information

NPI: 1154456549
Provider Name (Legal Business Name): HIGHLANDS OF DYERSBURG, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2007
Last Update Date: 06/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 TICKLE STREET
DYERSBURG TN
38024
US

IV. Provider business mailing address

485 CENTRAL AVENUE NE
CLEVELAND TN
37311
US

V. Phone/Fax

Practice location:
  • Phone: 731-285-9710
  • Fax: 731-285-9949
Mailing address:
  • Phone: 423-478-5953
  • Fax: 423-472-6283

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number0000000076
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateTN

VIII. Authorized Official

Name: DENNY BARNETT
Title or Position: MEMBER
Credential:
Phone: 423-478-5953