Basic Information
| Provider Information | |||||||||
| NPI: | 1750360152 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | IMPERIAL MANOR CONVALESCENT CENTER LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | IMPERIAL GARDENS HEALTH AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6 CADILLAC DR | ||||||||
| Address2: | SUITE 310 | ||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370275080 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152507100 | ||||||||
| FaxNumber: | 6152507102 | ||||||||
| Practice Location | |||||||||
| Address1: | 306 W DUE WEST AVE | ||||||||
| Address2: | |||||||||
| City: | MADISON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 371154511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6158655001 | ||||||||
| FaxNumber: | 6158650321 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 11/04/2009 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | HEBERT | ||||||||
| AuthorizedOfficialFirstName: | KIRK | ||||||||
| AuthorizedOfficialMiddleName: | F | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6152507100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VANGUARD HEALTHCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0000000053 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7440514 | 05 | TN | MEDICAID | 0445047 | 05 | TN | MEDICAID |