MEDICARE: CLARKSVILLE SENIOR CARE, 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	332BN1400X	Nursing Facility Supplies (DME)	NH2745	VA

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	:	1518915651
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARKSVILLE SENIOR CARE, LLC

Provider Business Mailing Address
First Line	:	PO BOX 649
Second Line	:
City	:	SOUTH BOSTON
State	:	VA
Zip	:	24592-0649
Country	:	US
Telephone Number	:	434-517-3085
Fax Number	:	434-517-3721

Provider Business Practice Location Address
First Line	:	184 BUFFALO RD
Second Line	:
City	:	CLARKSVILLE
State	:	VA
Zip	:	23927
Country	:	US
Telephone Number	:	434-374-4141
Fax Number	:	434-374-4491

Authorized Official
Title or Position	:	CHIEF FINANCIAL OFFICER
Name	:	MR. STEWART NELSON
Credential	:
Telephone Number	:	434-517-3183

Provider Enumeration Date	:	05/04/2006
Last Update Date	:	02/14/2008

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