Healthcare Provider Details

I. General information

NPI: 1861664955
Provider Name (Legal Business Name): REELFOOT OPERATOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2008
Last Update Date: 01/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1034 REELFOOT ST
TIPTONVILLE TN
38079-1607
US

IV. Provider business mailing address

1034 REELFOOT ST
TIPTONVILLE TN
38079-1607
US

V. Phone/Fax

Practice location:
  • Phone: 731-253-6681
  • Fax: 731-253-8014
Mailing address:
  • Phone: 731-253-6681
  • Fax: 731-253-8014

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number0000000151
License Number StateTN

VIII. Authorized Official

Name: LORI A. CHAMBERS
Title or Position: ADMINISTRATOR
Credential:
Phone: 731-253-6681