Healthcare Provider Details

I. General information

NPI: 1659707743
Provider Name (Legal Business Name): FAYETTEVILLE HEALTHCARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/19/2013
Last Update Date: 03/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4081 THORNTON TAYLOR PKWY
FAYETTEVILLE TN
37334-2674
US

IV. Provider business mailing address

4081 THORNTON TAYLOR PKWY
FAYETTEVILLE TN
37334-2674
US

V. Phone/Fax

Practice location:
  • Phone: 931-433-9773
  • Fax:
Mailing address:
  • Phone: 931-433-9973
  • Fax:

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: THOMAS D JOHNSON
Title or Position: CHIEF MANAGER
Credential:
Phone: 423-478-5953