Provider Demographics
NPI:1154456549
Name:HIGHLANDS OF DYERSBURG, LLC
Entity Type:Organization
Organization Name:HIGHLANDS OF DYERSBURG, LLC
Other - Org Name:HIGHLANDS OF DYERSBURG HEALTH & REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:DENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-478-5953
Mailing Address - Street 1:485 CENTRAL AVENUE NE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311
Mailing Address - Country:US
Mailing Address - Phone:423-478-5953
Mailing Address - Fax:423-472-6283
Practice Address - Street 1:350 TICKLE STREET
Practice Address - Street 2:
Practice Address - City:DYERSBURG
Practice Address - State:TN
Practice Address - Zip Code:38024
Practice Address - Country:US
Practice Address - Phone:731-285-9710
Practice Address - Fax:731-285-9949
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-23
Last Update Date:2009-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000076313M00000X
TN314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440397Medicaid