Healthcare Provider Details

I. General information

NPI: 1821524075
Provider Name (Legal Business Name): HIS HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2017
Last Update Date: 05/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5010 MOUNT ZION RD
SPRINGFIELD TN
37172-7130
US

IV. Provider business mailing address

5010 MT ZION RD
SPRINGFIELD TN
37172
US

V. Phone/Fax

Practice location:
  • Phone: 931-881-6417
  • Fax:
Mailing address:
  • Phone: 931-881-6417
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberTNPL536621
License Number StateTN

VIII. Authorized Official

Name: CONNIE MITCHELL
Title or Position: ADMINISTRATOR
Credential:
Phone: 931-881-6417