Healthcare Provider Details

I. General information

NPI: 1639804636
Provider Name (Legal Business Name): OPEN HEART COMMUNITY FOUNDATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2022
Last Update Date: 08/23/2022
Certification Date: 08/23/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1981 KANSAS ST
MEMPHIS TN
38109-1968
US

IV. Provider business mailing address

5363 RAVENDALE AVE
MEMPHIS TN
38134-4430
US

V. Phone/Fax

Practice location:
  • Phone: 901-409-1228
  • Fax:
Mailing address:
  • Phone: 901-409-1228
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. TIFFANY LASHAY RUCKER
Title or Position: PSSA
Credential: PSSA
Phone: 901-409-9740