MEDICARE: CENTERVILLE MEDICAL INVESTORS, 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	314000000X	Skilled Nursing Facility	131	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1326074402
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CENTERVILLE MEDICAL INVESTORS, LLC

Provider Business Mailing Address
First Line	:	3001 KEITH ST NW
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37312-3713
Country	:	US
Telephone Number	:	423-473-5751
Fax Number	:	423-339-8342

Provider Business Practice Location Address
First Line	:	112 OLD DICKSON ROAD
Second Line	:
City	:	CENTERVILLE
State	:	TN
Zip	:	37033
Country	:	US
Telephone Number	:	931-729-4236
Fax Number	:	931-729-5489

Authorized Official
Title or Position	:	ASSISTANT SECRETARY
Name	:	CINDY S CROSS
Credential	:
Telephone Number	:	423-473-5867

Provider Enumeration Date	:	06/23/2006
Last Update Date	:	02/12/2008

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