Healthcare Provider Details

I. General information

NPI: 1235676156
Provider Name (Legal Business Name): CLC OF HARRIMAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/30/2017
Last Update Date: 05/26/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

257 PATTON LN
HARRIMAN TN
37748-8618
US

IV. Provider business mailing address

PO BOX 3667
TUPELO MS
38803-3667
US

V. Phone/Fax

Practice location:
  • Phone: 865-354-3941
  • Fax:
Mailing address:
  • Phone: 662-680-3148
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code313M00000X
TaxonomyNursing Facility/Intermediate Care Facility
License Number212
License Number StateTN
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number212
License Number StateTN

VIII. Authorized Official

Name: DOUGLAS M WRIGHT JR.
Title or Position: MANAGING MEMBER
Credential:
Phone: 662-680-3148