MEDICARE: PRESTIGE CARE HOME/ANGELIC VISITS

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	310400000X	Assisted Living Facility	0000000565	TN
2	251E00000X	Home Health Agency	0000000565	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	:	1649656844
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	PRESTIGE CARE HOME/ANGELIC VISITS

Provider Business Mailing Address
First Line	:	2051 MONTREAT DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38134-6613
Country	:	US
Telephone Number	:	901-281-8292
Fax Number	:	901-388-7366

Provider Business Practice Location Address
First Line	:	2051 MONTREAT DR
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38134-6613
Country	:	US
Telephone Number	:	901-281-8292
Fax Number	:	901-388-7366

Authorized Official
Title or Position	:	NURSE ADMINISTRATOR
Name	:	SHIRLEY SPILLER-JOHNSON
Credential	:
Telephone Number	:	901-281-8292

Provider Enumeration Date	:	08/11/2015
Last Update Date	:	08/11/2015

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