Healthcare Provider Details

I. General information

NPI: 1205389657
Provider Name (Legal Business Name): THE WATERS OF ROAN HIGHLANDS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/02/2016
Last Update Date: 08/02/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

146 BUCK CREEK RD
ROAN MOUNTAIN TN
37687-3497
US

IV. Provider business mailing address

146 BUCK CREEK RD
ROAN MOUNTAIN TN
37687-3497
US

V. Phone/Fax

Practice location:
  • Phone: 423-772-0161
  • Fax: 423-772-3481
Mailing address:
  • Phone: 423-772-0161
  • Fax: 423-772-3481

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: MOISHE GUBIN
Title or Position: MEMBER
Credential:
Phone: 708-449-1900