Healthcare Provider Details

I. General information

NPI: 1902825151
Provider Name (Legal Business Name): KEYSTONE CONTINUUM, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

415 SEVEN HAWKS LN
WAVERLY TN
37185-2536
US

IV. Provider business mailing address

415 SEVEN HAWKS LN
WAVERLY TN
37185-2536
US

V. Phone/Fax

Practice location:
  • Phone: 931-296-1183
  • Fax: 931-296-7576
Mailing address:
  • Phone: 931-296-1183
  • Fax: 931-296-7576

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code323P00000X
TaxonomyPsychiatric Residential Treatment Facility
License NumberSO09869A
License Number StateTN

VIII. Authorized Official

Name: TOM HENNESSEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 931-296-1183