Healthcare Provider Details

I. General information

NPI: 1649656844
Provider Name (Legal Business Name): PRESTIGE CARE HOME/ANGELIC VISITS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/11/2015
Last Update Date: 08/11/2015
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 TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number0000000565
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number0000000565
License Number StateTN

VIII. Authorized Official

Name: SHIRLEY SPILLER-JOHNSON
Title or Position: NURSE ADMINISTRATOR
Credential:
Phone: 901-281-8292