Provider Demographics
NPI:1285624361
Name:JEFFERSON COUNTY NURSING HOME
Entity type:Organization
Organization Name:JEFFERSON COUNTY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:L
Authorized Official - Last Name:MYNATT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-397-3163
Mailing Address - Street 1:914 INDUSTRIAL PARK RD
Mailing Address - Street 2:
Mailing Address - City:DANDRIDGE
Mailing Address - State:TN
Mailing Address - Zip Code:37725-4700
Mailing Address - Country:US
Mailing Address - Phone:865-397-3163
Mailing Address - Fax:865-397-4225
Practice Address - Street 1:914 INDUSTRIAL PARK RD
Practice Address - Street 2:
Practice Address - City:DANDRIDGE
Practice Address - State:TN
Practice Address - Zip Code:37725-4700
Practice Address - Country:US
Practice Address - Phone:865-397-3163
Practice Address - Fax:865-397-4225
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-28
Last Update Date:2007-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN138314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440105Medicaid
TN7440105Medicaid