MEDICARE: HOLSTON MANOR SNF OPERATIONS 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

General Provider Information

NPI Number	:	1669136123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HOLSTON MANOR SNF OPERATIONS LLC

Provider Business Mailing Address
First Line	:	3641 MEMORIAL BLVD
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-3422
Country	:	US
Telephone Number	:	423-246-2411
Fax Number	:

Provider Business Practice Location Address
First Line	:	3641 MEMORIAL BLVD
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-3422
Country	:	US
Telephone Number	:	423-246-2411
Fax Number	:

Authorized Official
Title or Position	:	AUTHORIZED OFFICIAL
Name	:	MENUCHA GOODMAN
Credential	:
Telephone Number	:	732-268-1810

Provider Enumeration Date	:	10/29/2021
Last Update Date	:	02/04/2026

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