Basic Information
| Provider Information | |||||||||
| NPI: | 1003061334 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIGHLANDS OF DYERSBURG LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | THE HIGHLANDS OF DYERSBURG HEALTH & REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 350 E TICKLE ST | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380243118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312859710 | ||||||||
| FaxNumber: | 7312859949 | ||||||||
| Practice Location | |||||||||
| Address1: | 350 E TICKLE ST | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380243118 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312859710 | ||||||||
| FaxNumber: | 7312859949 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/01/2008 | ||||||||
| LastUpdateDate: | 12/01/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BARNETT | ||||||||
| AuthorizedOfficialFirstName: | ROBERT | ||||||||
| AuthorizedOfficialMiddleName: | DENNY | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4439045200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
No ID Information.