Basic Information
| Provider Information | |||||||||
| NPI: | 1891012043 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MOUNT PLEASANT HEALTHCARE LLC | ||||||||
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| OtherOrganizationName: | HIDDEN ACRES HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7201 SHALLOWFORD RD | ||||||||
| Address2: | SUITE 200 | ||||||||
| City: | CHATTANOOGA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 374212780 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4233081845 | ||||||||
| FaxNumber: | 4233081848 | ||||||||
| Practice Location | |||||||||
| Address1: | 904 HIDDEN ACRES AVE | ||||||||
| Address2: | |||||||||
| City: | MOUNT PLEASANT | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384741039 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9313795502 | ||||||||
| FaxNumber: | 9313795504 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2010 | ||||||||
| LastUpdateDate: | 04/28/2010 | ||||||||
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| AuthorizedOfficialLastName: | MATHENY | ||||||||
| AuthorizedOfficialFirstName: | CYNTHIA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF FACILITY ACCOUNTING | ||||||||
| AuthorizedOfficialTelephone: | 4234241839 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0445374 | 05 | TN | MEDICAID | 7440341 | 05 | TN | MEDICAID |