Provider Demographics
NPI:1316018286
Name:BOLIVAR OPERATOR LLC
Entity Type:Organization
Organization Name:BOLIVAR OPERATOR LLC
Other - Org Name:PINE MEADOWS HEALTHCARE AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-429-8062
Mailing Address - Street 1:7400 NEW LA GRANGE RD
Mailing Address - Street 2:SUITE #100
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4870
Mailing Address - Country:US
Mailing Address - Phone:502-429-8062
Mailing Address - Fax:502-429-0650
Practice Address - Street 1:700 NUCKOLLS RD
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008-1531
Practice Address - Country:US
Practice Address - Phone:731-658-4707
Practice Address - Fax:731-658-4769
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN171314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
445232Medicare Oscar/Certification