Basic Information
| Provider Information | |||||||||
| NPI: | 1063730778 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAYNE CARE NURSING HOME | ||||||||
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| Mailing Information | |||||||||
| Address1: | 505 S HIGH ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384852610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317225832 | ||||||||
| FaxNumber: | 9317226522 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S HIGH ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384852610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317225832 | ||||||||
| FaxNumber: | 9317226522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/06/2010 | ||||||||
| LastUpdateDate: | 05/19/2014 | ||||||||
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| AuthorizedOfficialLastName: | STULTS | ||||||||
| AuthorizedOfficialFirstName: | TAMMY | ||||||||
| AuthorizedOfficialMiddleName: | L | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 9317225832 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | RN | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 277 | TN | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 7440515 | 05 | TN | MEDICAID |