=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457736332
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MADISONVILLE HEALTHCARE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/21/2015
-----------------------------------------------------
Last Update Date | 03/28/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 465 ISBILL RD
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37354-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-478-5953
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 465 ISBILL RD
-----------------------------------------------------
City | MADISONVILLE
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37354-2112
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | TREASURER
-----------------------------------------------------
Name | KENNETH C HART JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-584-6755
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 0186
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------