Provider Demographics
NPI:1043275639
Name:HUMBOLDT HEALTHCARE AND REHAB CENTER, LLC
Entity Type:Organization
Organization Name:HUMBOLDT HEALTHCARE AND REHAB CENTER, LLC
Other - Org Name:HUMBOLDT ACQUISITION CORP
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MS
Authorized Official - First Name:ROBIN
Authorized Official - Middle Name:F
Authorized Official - Last Name:BRADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-595-8383
Mailing Address - Street 1:PO BOX 10
Mailing Address - Street 2:
Mailing Address - City:PARSONS
Mailing Address - State:TN
Mailing Address - Zip Code:38363-0010
Mailing Address - Country:US
Mailing Address - Phone:731-847-6343
Mailing Address - Fax:731-847-4200
Practice Address - Street 1:2031 AVONDALE ST
Practice Address - Street 2:
Practice Address - City:HUMBOLDT
Practice Address - State:TN
Practice Address - Zip Code:38343
Practice Address - Country:US
Practice Address - Phone:731-784-3655
Practice Address - Fax:731-784-3651
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AMERICAN HEALTH COMPANIES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-18
Last Update Date:2021-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0086313M00000X
TN0000000190314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN744-0531Medicaid
TN744-0531Medicaid