Basic Information
| Provider Information | |||||||||
| NPI: | 1538467717 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HEALTH SERVICES MANCHESTER, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 485 CENTRAL AVE NE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373115541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234785953 | ||||||||
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| Practice Location | |||||||||
| Address1: | 811 KEYLON STREET | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373552419 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9314613425 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/11/2011 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | HART | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 4235846755 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0000000033 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7440354 | 05 | TN | MEDICAID | 0445383 | 05 | TN | MEDICAID |