Basic Information
| Provider Information | |||||||||
| NPI: | 1972181998 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CHRISTIAN CARE CENTER OF BOLIVAR LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2020 NORTHPARK DR STE 2D | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376043127 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239755455 | ||||||||
| FaxNumber: | 4233900743 | ||||||||
| Practice Location | |||||||||
| Address1: | 10160 HIGHWAY 64W | ||||||||
| Address2: | |||||||||
| City: | BOLIVAR | ||||||||
| State: | TN | ||||||||
| PostalCode: | 38008 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4239755455 | ||||||||
| FaxNumber: | 4233900743 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2021 | ||||||||
| LastUpdateDate: | 01/31/2022 | ||||||||
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| AuthorizedOfficialLastName: | CAWOOD GRAY | ||||||||
| AuthorizedOfficialFirstName: | LISA | ||||||||
| AuthorizedOfficialMiddleName: | M | ||||||||
| AuthorizedOfficialTitleorPosition: | DELEGATED OFFICIAL, REGISTRATIONS O | ||||||||
| AuthorizedOfficialTelephone: | 4235576116 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| NPICertificationDate: | 01/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.