Provider Demographics
NPI:1063509271
Name:COFFEE MEDICAL GROUP LLC
Entity Type:Organization
Organization Name:COFFEE MEDICAL GROUP LLC
Other - Org Name:UNITED REGIONAL MEDICAL CENTER NURSING HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:HOLLY
Authorized Official - Middle Name:B
Authorized Official - Last Name:HOPKINS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-461-3425
Mailing Address - Street 1:1001 MCARTHUR DRIVE
Mailing Address - Street 2:
Mailing Address - City:MANCHESTER
Mailing Address - State:TN
Mailing Address - Zip Code:37355
Mailing Address - Country:US
Mailing Address - Phone:931-728-3586
Mailing Address - Fax:931-723-0781
Practice Address - Street 1:1001 MCARTHUR DRIVE
Practice Address - Street 2:
Practice Address - City:MANCHESTER
Practice Address - State:TN
Practice Address - Zip Code:37355
Practice Address - Country:US
Practice Address - Phone:931-728-3586
Practice Address - Fax:931-723-0781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-07
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN7440354313M00000X
TN445383314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4039933OtherBCBS
TN0445383Medicaid
TN7440354Medicaid
TN7440354Medicaid