Basic Information
| Provider Information | |||||||||
| NPI: | 1992119010 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WAYNESBORO HEALTHCARE, LLC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | WAYNE CARE NURSING HOME | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 485 CENTRAL AVE NE | ||||||||
| Address2: | |||||||||
| City: | CLEVELAND | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373115541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234785953 | ||||||||
| FaxNumber: | 4234726283 | ||||||||
| Practice Location | |||||||||
| Address1: | 505 S HIGH ST | ||||||||
| Address2: | |||||||||
| City: | WAYNESBORO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 384852610 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317225832 | ||||||||
| FaxNumber: | 9317226522 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/17/2014 | ||||||||
| LastUpdateDate: | 03/28/2019 | ||||||||
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| AuthorizedOfficialLastName: | HART | ||||||||
| AuthorizedOfficialFirstName: | KENNETH | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | TREASURER | ||||||||
| AuthorizedOfficialTelephone: | 4235846755 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | JR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0000000277 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.