Basic Information
| Provider Information | |||||||||
| NPI: | 1568039436 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WATERS OF MEMPHIS A REHABILITATION & NURSING CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 240 FENCL LN | ||||||||
| Address2: | |||||||||
| City: | HILLSIDE | ||||||||
| State: | IL | ||||||||
| PostalCode: | 601622067 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7084491900 | ||||||||
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| Practice Location | |||||||||
| Address1: | 6500 KIRBY GATE BLVD | ||||||||
| Address2: | |||||||||
| City: | MEMPHIS | ||||||||
| State: | TN | ||||||||
| PostalCode: | 381192673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9017520772 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/08/2021 | ||||||||
| LastUpdateDate: | 06/08/2021 | ||||||||
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| AuthorizedOfficialLastName: | BLISKO | ||||||||
| AuthorizedOfficialFirstName: | MICHAEL | ||||||||
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| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7084491900 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/08/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.