Healthcare Provider Details

I. General information

NPI: 1588403224
Provider Name (Legal Business Name): CORDERRO CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/22/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 S ROYAL ST STE 38
JACKSON TN
38301-7307
US

IV. Provider business mailing address

575 S ROYAL ST STE 38
JACKSON TN
38301-7307
US

V. Phone/Fax

Practice location:
  • Phone: 901-239-3812
  • Fax:
Mailing address:
  • Phone: 901-239-3812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: AMAYA NICOLE JOHNSON
Title or Position: DIRECTOR/OWNER
Credential: CLPN
Phone: 901-239-3812