=====================================================
General NPI Number Information
=====================================================
NPI Number | 1740279777
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | RURAL LIFE FOUNDATION, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/21/2005
-----------------------------------------------------
Last Update Date | 12/12/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3575 LONESOME PINE RD
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38372-5409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-925-7221
-----------------------------------------------------
Fax | 731-926-3400
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3575 LONESOME PINE RD
-----------------------------------------------------
City | SAVANNAH
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38372-5409
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 731-925-7221
-----------------------------------------------------
Fax | 731-926-3400
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. RANDALL LEE DICKMAN
-----------------------------------------------------
Credential | NHA
-----------------------------------------------------
Telephone | 731-925-7221
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 0000000118
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------