Basic Information
| Provider Information | |||||||||
| NPI: | 1811218324 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTIAN CARE CENTER OF RUTHERFORD COUNTY LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 NORTHPARK | ||||||||
| Address2: | SUITE 2D | ||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376043127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239755455 | ||||||||
| FaxNumber: | 4239755405 | ||||||||
| Practice Location | |||||||||
| Address1: | 202 ENON SPRINGS ROAD EAST | ||||||||
| Address2: | |||||||||
| City: | SMYRNA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37167 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6154595600 | ||||||||
| FaxNumber: | 6154597022 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/18/2010 | ||||||||
| LastUpdateDate: | 02/13/2012 | ||||||||
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| AuthorizedOfficialLastName: | CAWOOD-GRAY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M. | ||||||||
| AuthorizedOfficialTitleorPosition: | RISK CONSULTANT | ||||||||
| AuthorizedOfficialTelephone: | 4239755455 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 0000000221 | TN | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 0000000221 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0445502 | 05 | TN | MEDICAID | 7440610 | 05 | TN | MEDICAID |