Basic Information
| Provider Information | |||||||||
| NPI: | 1184613143 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHADY LAWN, LLC | ||||||||
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| OtherOrganizationName: | SHADY LAWN HEALTH AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9020 OVERLOOK BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370272755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152507100 | ||||||||
| FaxNumber: | 6152507101 | ||||||||
| Practice Location | |||||||||
| Address1: | 60 SHADY LAWN PL | ||||||||
| Address2: | |||||||||
| City: | VICKSBURG | ||||||||
| State: | MS | ||||||||
| PostalCode: | 39180 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6016361448 | ||||||||
| FaxNumber: | 6016368811 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/20/2005 | ||||||||
| LastUpdateDate: | 05/24/2018 | ||||||||
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| AuthorizedOfficialLastName: | ORAND | ||||||||
| AuthorizedOfficialFirstName: | WILLIAM | ||||||||
| AuthorizedOfficialMiddleName: | D. | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 6152507100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VANGUARD HEALTHCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 182 | MS | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 00220335 | 05 | MS | MEDICAID |