Provider Demographics
NPI:1093255101
Name:AVE MARIA HOME DBA ST. CLARE HEALTH AND REHAB, LLC
Entity Type:Organization
Organization Name:AVE MARIA HOME DBA ST. CLARE HEALTH AND REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ASSISTANT EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:MARLENE
Authorized Official - Middle Name:
Authorized Official - Last Name:SIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-386-3211
Mailing Address - Street 1:1755 ELDRIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38108-1115
Mailing Address - Country:US
Mailing Address - Phone:901-278-3840
Mailing Address - Fax:901-278-3841
Practice Address - Street 1:1755 ELDRIDGE AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38108-1115
Practice Address - Country:US
Practice Address - Phone:901-278-3840
Practice Address - Fax:901-278-3841
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:AVE MARIA HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2017-03-08
Last Update Date:2017-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000250313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440538Medicaid
TN445493Medicare Oscar/Certification