Healthcare Provider Details

I. General information

NPI: 1568564425
Provider Name (Legal Business Name): PRIVATE SENIOR PROVIDERS ETP LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/02/2006
Last Update Date: 08/01/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

234 PANDORA ST CO/BRENDA THOMPSON
MEMPHIS TN
38117-2855
US

IV. Provider business mailing address

PO BOX 770193
MEMPHIS TN
38177-0193
US

V. Phone/Fax

Practice location:
  • Phone: 901-315-8619
  • Fax: 901-763-2907
Mailing address:
  • Phone: 901-315-8619
  • Fax: 901-761-2907

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number
License Number State

VIII. Authorized Official

Name: MRS. NANCY SHERMAN GILLESPIE
Title or Position: OWNER
Credential: HOME HEALTH AIDE
Phone: 901-315-8619