Provider Demographics
NPI:1134111081
Name:DHS OF BLOUNT COUNTY, LLC
Entity Type:Organization
Organization Name:DHS OF BLOUNT COUNTY, LLC
Other - Org Name:TLC NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAREN
Authorized Official - Middle Name:SUE
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-625-3520
Mailing Address - Street 1:212 ELLEN ST
Mailing Address - Street 2:P.O. BOX 698
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-2720
Mailing Address - Country:US
Mailing Address - Phone:205-625-3520
Mailing Address - Fax:205-625-3680
Practice Address - Street 1:212 ELLEN ST
Practice Address - Street 2:
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-2720
Practice Address - Country:US
Practice Address - Phone:205-625-3520
Practice Address - Fax:205-625-3680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-17
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10468314000000X
TN332BP3500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No332BP3500XSuppliersDurable Medical Equipment & Medical SuppliesParenteral & Enteral Nutrition
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51521486OtherBLUE CROSS BLUE SHIELD
AL4757940SMedicaid
AL011251OtherBLUE CROSS BLUE SHIELD
AL=========OtherFEDERAL ID NUMBER
AL=========OtherFEDERAL ID NUMBER
AL4165600001Medicare NSC