Provider Demographics
NPI:1275995623
Name:DOMINION MARYVILLE,LLC
Entity Type:Organization
Organization Name:DOMINION MARYVILLE,LLC
Other - Org Name:CLOVER HILL SENIOR LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:FRED
Authorized Official - Middle Name:
Authorized Official - Last Name:WHEELER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:865-238-5338
Mailing Address - Street 1:2317 US HIGHWAY 411 S
Mailing Address - Street 2:
Mailing Address - City:MARYVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37801-8634
Mailing Address - Country:US
Mailing Address - Phone:865-238-5338
Mailing Address - Fax:
Practice Address - Street 1:2317 US HIGHWAY 411 S
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:TN
Practice Address - Zip Code:37801-8634
Practice Address - Country:US
Practice Address - Phone:865-238-5338
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-24
Last Update Date:2016-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN423310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility