Healthcare Provider Details

I. General information

NPI: 1770049504
Provider Name (Legal Business Name): JELLICO TN OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/18/2019
Last Update Date: 02/07/2023
Certification Date: 02/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

240 HOSPITAL LN
JELLICO TN
37762-4401
US

IV. Provider business mailing address

2071 FLATBUSH AVE STE 12
BROOKLYN NY
11234-4340
US

V. Phone/Fax

Practice location:
  • Phone: 423-784-6626
  • Fax:
Mailing address:
  • Phone:
  • 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: DAVID HERSKOWITZ
Title or Position: CEO
Credential:
Phone: 212-444-1991