Provider Demographics
NPI:1154813228
Name:TAZEWELL LIFE CARE, LLC
Entity Type:Organization
Organization Name:TAZEWELL LIFE CARE, LLC
Other - Org Name:HERITAGE HALL - TAZEWELL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CCO & GENERAL COUNSEL
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:L
Authorized Official - Last Name:HAINES
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:540-774-4263
Mailing Address - Street 1:282 BEN BOLT AVE
Mailing Address - Street 2:
Mailing Address - City:TAZEWELL
Mailing Address - State:VA
Mailing Address - Zip Code:24651-5384
Mailing Address - Country:US
Mailing Address - Phone:276-988-2515
Mailing Address - Fax:276-988-5468
Practice Address - Street 1:282 BEN BOLT AVE
Practice Address - Street 2:
Practice Address - City:TAZEWELL
Practice Address - State:VA
Practice Address - Zip Code:24651-5384
Practice Address - Country:US
Practice Address - Phone:276-988-2515
Practice Address - Fax:276-988-5468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-04
Last Update Date:2018-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2581314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
200515601OtherFEDERAL BLACK LUNG
418359OtherCOMBINED INS CO OF AMERICA
180511OtherANTHEM BCBS
VA4951522Medicaid