Provider Demographics
NPI:1356606735
Name:EXTENDICARE OF WEST TN
Entity type:Organization
Organization Name:EXTENDICARE OF WEST TN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HYSICAL THERAPIST ASSISTANT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHELLEY
Authorized Official - Middle Name:DAWN
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:PTA
Authorized Official - Phone:731-660-2171
Mailing Address - Street 1:97 THORNFIELD DR
Mailing Address - Street 2:
Mailing Address - City:BELLS
Mailing Address - State:TN
Mailing Address - Zip Code:38006-5128
Mailing Address - Country:US
Mailing Address - Phone:731-660-2171
Mailing Address - Fax:731-660-2171
Practice Address - Street 1:250 N PARKWAY
Practice Address - Street 2:SUITE 4
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2735
Practice Address - Country:US
Practice Address - Phone:731-668-1372
Practice Address - Fax:731-664-9919
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LHC GROUP
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN4019251C00000X, 251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No251C00000XAgenciesDay Training, Developmentally Disabled Services