Basic Information
| Provider Information | |||||||||
| NPI: | 1346419173 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTER FOR ADULT HEALTHCARE LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 689022 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPARTMENT | ||||||||
| City: | FRANKLIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370689022 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1629 WOODLAWN AVE | ||||||||
| Address2: | |||||||||
| City: | DYERSBURG | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380242025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7312852324 | ||||||||
| FaxNumber: | 7312851440 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/26/2008 | ||||||||
| LastUpdateDate: | 05/18/2011 | ||||||||
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| AuthorizedOfficialLastName: | BREWER | ||||||||
| AuthorizedOfficialFirstName: | DEBBIE | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6154657626 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | TN | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 207R00000X | TN | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 3370274 | 05 | TN | MEDICAID | 9140162 | 01 | TN | AETNA | OTHER |