Provider Demographics
NPI:1992784326
Name:VANGUARD OF MANCHESTER, LLC
Entity type:Organization
Organization Name:VANGUARD OF MANCHESTER, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:T
Authorized Official - Last Name:FICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-250-7100
Mailing Address - Street 1:9020 OVERLOOK BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2755
Mailing Address - Country:US
Mailing Address - Phone:615-250-7100
Mailing Address - Fax:615-250-7101
Practice Address - Street 1:395 INTERSTATE DR
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355
Practice Address - Country:US
Practice Address - Phone:931-723-8744
Practice Address - Fax:931-723-8738
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VANGUARD HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-13
Last Update Date:2018-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000355314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440587Medicaid
TN0445391Medicaid
TN0445391Medicaid