=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285343541
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW LEROY GRIFFITH LNHA
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2022
-----------------------------------------------------
Last Update Date | 11/15/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 293 KING RD
-----------------------------------------------------
City | TRACY CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37387-4613
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-592-9621
-----------------------------------------------------
Fax | 931-592-9622
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 615 JOHNNY STIEFEL RD
-----------------------------------------------------
City | SEQUATCHIE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37374-6158
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 931-581-3728
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 376G00000X
-----------------------------------------------------
Taxonomy Name | Nursing Home Administrator
-----------------------------------------------------
License Number | 3905
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------