Basic Information
| Provider Information | |||||||||
| NPI: | 1386803310 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITES CREEK HEALTHCARE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRACE HEALTHCARE OF WHITES CREEK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3425 KNIGHT DR | ||||||||
| Address2: | |||||||||
| City: | WHITES CREEK | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371899189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158762754 | ||||||||
| FaxNumber: | 6158769499 | ||||||||
| Practice Location | |||||||||
| Address1: | 3425 KNIGHT DR | ||||||||
| Address2: | |||||||||
| City: | WHITES CREEK | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371899189 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158762754 | ||||||||
| FaxNumber: | 6158769499 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2008 | ||||||||
| LastUpdateDate: | 06/05/2008 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | CLARK DANKS | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 4233081845 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GRACE HEALTHCARE LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | CPA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 69 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0445281 | 05 | TN | MEDICAID | 7440544 | 05 | TN | MEDICAID |