Healthcare Provider Details

I. General information

NPI: 1609264142
Provider Name (Legal Business Name): PRESTIGE CARE HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2015
Last Update Date: 01/07/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2051 MONTREAT DR
MEMPHIS TN
38134-6613
US

IV. Provider business mailing address

2051 MONTREAT DR
MEMPHIS TN
38134-6613
US

V. Phone/Fax

Practice location:
  • Phone: 901-281-8292
  • Fax: 901-388-7366
Mailing address:
  • Phone: 901-281-8292
  • Fax: 901-388-7366

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0000000565
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number0000000565
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number0000000565
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number0000000565
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number0000000565
License Number StateTN
# 6
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number0000000565
License Number StateTN

VIII. Authorized Official

Name: SHIRLEY SPILLER-JOHNSON
Title or Position: OWNER/ADMINISTRATOR
Credential: LPN
Phone: 901-281-8292