Basic Information
| Provider Information | |||||||||
| NPI: | 1255521555 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LP ELIZABETHTON LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SIGNATURE HEALTHCARE OF ELIZABETHTON REHAB & WELLNESS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12201 BLUEGRASS PKWY | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402992361 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5025687800 | ||||||||
| FaxNumber: | 5025687150 | ||||||||
| Practice Location | |||||||||
| Address1: | 1200 SPRUCE LN | ||||||||
| Address2: | |||||||||
| City: | ELIZABETHTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376434301 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4235433202 | ||||||||
| FaxNumber: | 4235436249 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/01/2007 | ||||||||
| LastUpdateDate: | 04/05/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HARRISON | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 5025687800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | LP CR HOLDINGS LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 27 | TN | N | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 313M00000X | 27 | TN | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 0445217 | 05 | TN | MEDICAID | 7440568 | 05 | TN | MEDICAID |