Basic Information
| Provider Information | |||||||||
| NPI: | 1992784326 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | VANGUARD OF MANCHESTER, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MANCHESTER HEALTH CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 9020 OVERLOOK BLVD STE 202 | ||||||||
| Address2: | |||||||||
| City: | BRENTWOOD | ||||||||
| State: | TN | ||||||||
| PostalCode: | 370272755 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6152507100 | ||||||||
| FaxNumber: | 6152507101 | ||||||||
| Practice Location | |||||||||
| Address1: | 395 INTERSTATE DR | ||||||||
| Address2: | |||||||||
| City: | MANCHESTER | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37355 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317238744 | ||||||||
| FaxNumber: | 9317238738 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/13/2006 | ||||||||
| LastUpdateDate: | 05/24/2018 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FICK | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | T | ||||||||
| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6152507100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | VANGUARD HEALTHCARE, LLC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 0000000355 | TN | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 7440587 | 05 | TN | MEDICAID | 0445391 | 05 | TN | MEDICAID |