Basic Information
| Provider Information | |||||||||
| NPI: | 1871650895 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MRH DBA WMC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WAYNE CARE NURSING HOME | ||||||||
| OtherOrganizationType: | 4 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 103 JV MANGUBAT DRIVE | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317223641 | ||||||||
| FaxNumber: | 9317227215 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 SOUTH HIGH STREET | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38485 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317225832 | ||||||||
| FaxNumber: | 9317226522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/02/2007 | ||||||||
| LastUpdateDate: | 08/04/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BRINKLEY | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 9314054212 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MAURY REGIONAL HOSPITAL DBA WAYNE MEDICAL CENTER | ||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | III | ||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 08/04/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 277 | TN | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 7440515 | 05 | TN | MEDICAID |