Basic Information
| Provider Information | |||||||||
| NPI: | 1376574301 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFE CARE CENTERS OF AMERICA, INC. | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | LIFE CARE CENTER OF JEFFERSON CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3001 KEITH ST NW | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373123713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234735751 | ||||||||
| FaxNumber: | 4233398342 | ||||||||
| Practice Location | |||||||||
| Address1: | 336 W OLD ANDREW JOHNSON HWY | ||||||||
| Address2: | |||||||||
| City: | JEFFERSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377605212 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8654756097 | ||||||||
| FaxNumber: | 8654755236 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/06/2006 | ||||||||
| LastUpdateDate: | 09/15/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CROSS | ||||||||
| AuthorizedOfficialFirstName: | CINDY | ||||||||
| AuthorizedOfficialMiddleName: | S. | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 4234735867 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 139 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7440535 | 05 | TN | MEDICAID |