Basic Information
| Provider Information | |||||||||
| NPI: | 1477525905 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FMSC COLLIERVILLE OPERATING COMPANY | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | COLLIERVILLE HEALTH & REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 1055 NE 125TH ST | ||||||||
| Address2: | |||||||||
| City: | NORTH MIAMI | ||||||||
| State: | FL | ||||||||
| PostalCode: | 331615804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7868883310 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 490 W POPLAR AVE | ||||||||
| Address2: | |||||||||
| City: | COLLIERVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380172538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3058921790 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 12/03/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DUAY | ||||||||
| AuthorizedOfficialFirstName: | THEODORE | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 7868883310 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | C.P.A. | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 314000000 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 744-0470 | 05 | TN | MEDICAID |