Basic Information
| Provider Information | |||||||||
| NPI: | 1396213492 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOREST AVENUE OPCO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9020 OVERLOOK BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370272755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152507100 | ||||||||
| FaxNumber: | 6152507101 | ||||||||
| Practice Location | |||||||||
| Address1: | 1116 FOREST AVE | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MS | ||||||||
| PostalCode: | 392063216 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6013666461 | ||||||||
| FaxNumber: | 6013624041 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/06/2018 | ||||||||
| LastUpdateDate: | 11/06/2018 | ||||||||
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| AuthorizedOfficialLastName: | FICK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | THOMAS | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6152507100 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.