MEDICARE: MID-SOUTH HEALTH SERVICES, 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	0000000252	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
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1770684342
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MID-SOUTH HEALTH SERVICES, LLC

Provider Business Mailing Address
First Line	:	485 CENTRAL AVE NE
Second Line	:
City	:	CLEVELAND
State	:	TN
Zip	:	37311-5541
Country	:	US
Telephone Number	:	423-478-5953
Fax Number	:

Provider Business Practice Location Address
First Line	:	3030 WALNUT GROVE RD
Second Line	:
City	:	MEMPHIS
State	:	TN
Zip	:	38111-3508
Country	:	US
Telephone Number	:	901-458-1146
Fax Number	:

Authorized Official
Title or Position	:	CFO
Name	:	JEFF CANTRELL
Credential	:
Telephone Number	:	423-478-5953

Provider Enumeration Date	:	09/26/2006
Last Update Date	:	12/01/2011

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Directions to “MID-SOUTH HEALTH SERVICES, LLC ” Practice Location

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