Basic Information
| Provider Information | |||||||||
| NPI: | 1649258112 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CORNERSTONE HEALTH CARE OF MCKENZIE, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | OAK MANOR HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 OAK MANOR RD | ||||||||
| Address2: | |||||||||
| City: | MC KENZIE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382018846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7313525317 | ||||||||
| FaxNumber: | 7313525942 | ||||||||
| Practice Location | |||||||||
| Address1: | 150 OAK MANOR RD | ||||||||
| Address2: | |||||||||
| City: | MC KENZIE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 382018846 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7313525317 | ||||||||
| FaxNumber: | 7313525942 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/05/2006 | ||||||||
| LastUpdateDate: | 01/04/2010 | ||||||||
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| AuthorizedOfficialLastName: | MILENSKI | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 9194676649 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 24 | TN | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 24 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7440561 | 01 | TN | ICF MEDICAID | OTHER | 0445357 | 05 | TN | MEDICAID |