Provider Demographics
NPI:1982324182
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:MR
Authorized Official - First Name:ROGER
Authorized Official - Middle Name:LOUIS
Authorized Official - Last Name:MYNATT
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
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:865-397-3333
Practice Address - Street 1:407 LAURA LEE DR
Practice Address - Street 2:
Practice Address - City:WHITE PINE
Practice Address - State:TN
Practice Address - Zip Code:37890
Practice Address - Country:US
Practice Address - Phone:865-327-4100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:JEFFERSON COUNTY NURSING HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2022-08-30
Last Update Date:2022-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility