Basic Information
| Provider Information | |||||||||
| NPI: | 1881191450 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COVINGTON TN OPCO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAGNOLIA CREEK NURSING AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 212 2ND ST STE 501 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087013424 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7324971150 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1992 HIGHWAY 51 S | ||||||||
| Address2: | |||||||||
| City: | COVINGTON | ||||||||
| State: | TN | ||||||||
| PostalCode: | 380193623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9014761820 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/10/2018 | ||||||||
| LastUpdateDate: | 11/05/2018 | ||||||||
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| AuthorizedOfficialLastName: | HERBSTMAN | ||||||||
| AuthorizedOfficialFirstName: | MOSHE | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 7324971150 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | TN | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 385H00000X | TN | N | Respite Care Facility | Respite Care | 314000000X | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.