Provider Demographics
NPI:1235292871
Name:DICKSON HEALTHCARE LLC
Entity Type:Organization
Organization Name:DICKSON HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TYGH
Authorized Official - Middle Name:
Authorized Official - Last Name:BROGDON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:770-650-8773
Mailing Address - Street 1:1145 HEMBREE RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1122
Mailing Address - Country:US
Mailing Address - Phone:770-650-8773
Mailing Address - Fax:770-650-9732
Practice Address - Street 1:DICKSON HEALTHCARE CENTER
Practice Address - Street 2:901 NORTH CHARLOTTE STREET
Practice Address - City:DICKSON
Practice Address - State:TN
Practice Address - Zip Code:37055
Practice Address - Country:US
Practice Address - Phone:615-446-8150
Practice Address - Fax:615-446-7082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-18
Last Update Date:2008-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000072314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0445477Medicaid
TN0445477Medicaid