Provider Demographics
NPI:1033191390
Name:MCMINN MEMORIAL NURSING HOME
Entity Type:Organization
Organization Name:MCMINN MEMORIAL NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:D
Authorized Official - Last Name:MORRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-263-3779
Mailing Address - Street 1:886 HIGHWAY 411 N
Mailing Address - Street 2:
Mailing Address - City:ETOWAH
Mailing Address - State:TN
Mailing Address - Zip Code:37331-1912
Mailing Address - Country:US
Mailing Address - Phone:423-263-3600
Mailing Address - Fax:423-263-3607
Practice Address - Street 1:886 HIGHWAY 411 N
Practice Address - Street 2:
Practice Address - City:ETOWAH
Practice Address - State:TN
Practice Address - Zip Code:37331-1912
Practice Address - Country:US
Practice Address - Phone:423-263-3600
Practice Address - Fax:423-263-3607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-14
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000165313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440131Medicaid
TN1000652OtherBCBS OF TENNESSEE
TN0445277Medicaid
TN7440131Medicaid