Basic Information
| Provider Information | |||||||||
| NPI: | 1194776716 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SHELBY HEALTH SERVICES, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MIDSOUTH HEALTH & REHABILITATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 485 CENTRAL AVE NE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373115541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234785953 | ||||||||
| FaxNumber: | 4234790476 | ||||||||
| Practice Location | |||||||||
| Address1: | 2380 JAMES RD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381278806 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9013581707 | ||||||||
| FaxNumber: | 9013581788 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2006 | ||||||||
| LastUpdateDate: | 12/01/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CANTRELL | ||||||||
| AuthorizedOfficialFirstName: | JEFF | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 4234785953 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0248 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0445436 | 05 | TN | MEDICAID | 7440595 | 05 | TN | MEDICAID |