Provider Demographics
NPI:1083752901
Name:ST. MARY'S HOLSTON HEALTH AND REHABILITATION CENTER, INC.
Entity Type:Organization
Organization Name:ST. MARY'S HOLSTON HEALTH AND REHABILITATION CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:INTERIM CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANGEL
Authorized Official - Middle Name:DAVID
Authorized Official - Last Name:JIMENEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-545-7558
Mailing Address - Street 1:3916 BOYDS BRIDGE PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37914-6233
Mailing Address - Country:US
Mailing Address - Phone:865-524-1500
Mailing Address - Fax:865-524-0408
Practice Address - Street 1:3916 BOYDS BRIDGE PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37914-6233
Practice Address - Country:US
Practice Address - Phone:865-524-1500
Practice Address - Fax:865-524-0408
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ST. MARY'S HEALTH SYSTEM, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-02-02
Last Update Date:2009-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000333313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440572Medicaid