MEDICARE: SILVER ANGELS OF TENNESSEE - SHELBY, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	253Z00000X	In Home Supportive Care Agency

General Provider Information

NPI Number	:	1003161050
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SILVER ANGELS OF TENNESSEE - SHELBY, LLC

Provider Business Mailing Address
First Line	:	12201 BLUEGRASS PKWY
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40299-2361
Country	:	US
Telephone Number	:	502-568-7800
Fax Number	:

Provider Business Practice Location Address
First Line	:	6005 PARK AVE
Second Line	:	SUITE 111
City	:	MEMPHIS
State	:	TN
Zip	:	38119-5240
Country	:	US
Telephone Number	:	901-791-2174
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	MR. JOHN HARRISON
Credential	:
Telephone Number	:	502-568-7800

Provider Enumeration Date	:	07/16/2012
Last Update Date	:	10/30/2012

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