Provider Demographics
NPI:1235543463
Name:WAYNESBORO HEALTHCARE, LLC
Entity Type:Organization
Organization Name:WAYNESBORO HEALTHCARE, LLC
Other - Org Name:WAYNESBORO HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:HART
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:423-584-6755
Mailing Address - Street 1:104 JV MANGUBAT DR
Mailing Address - Street 2:
Mailing Address - City:WAYNESBORO
Mailing Address - State:TN
Mailing Address - Zip Code:38485-2439
Mailing Address - Country:US
Mailing Address - Phone:931-722-3641
Mailing Address - Fax:931-722-7215
Practice Address - Street 1:104 JV MANGUBAT DR
Practice Address - Street 2:
Practice Address - City:WAYNESBORO
Practice Address - State:TN
Practice Address - Zip Code:38485-2439
Practice Address - Country:US
Practice Address - Phone:931-722-3641
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-16
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000278314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440620Medicaid
TN0445518Medicaid