Healthcare Provider Details

I. General information

NPI: 1194702902
Provider Name (Legal Business Name): MILLINGTON OPCO LP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/22/2005
Last Update Date: 12/22/2023
Certification Date: 12/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5081 EASLEY ST
MILLINGTON TN
38053-2105
US

IV. Provider business mailing address

5081 EASLEY ST
MILLINGTON TN
38053-2105
US

V. Phone/Fax

Practice location:
  • Phone: 901-873-3290
  • Fax: 901-873-0531
Mailing address:
  • Phone: 901-873-3290
  • Fax: 901-873-0531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0000000316
License Number StateTN

VIII. Authorized Official

Name: MOSHE KELMAN
Title or Position: CEO
Credential:
Phone: 786-987-3707