Provider Demographics
NPI:1356504393
Name:HOLSTON NH OPERATIONS LLC
Entity Type:Organization
Organization Name:HOLSTON NH OPERATIONS LLC
Other - Org Name:HOLSTON MANOR
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:RHONDA
Authorized Official - Middle Name:B
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:864-578-6599
Mailing Address - Street 1:3641 MEMORIAL BLVD
Mailing Address - Street 2:
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37664-3422
Mailing Address - Country:US
Mailing Address - Phone:423-246-2411
Mailing Address - Fax:423-246-8997
Practice Address - Street 1:3641 MEMORIAL BLVD
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37664-3422
Practice Address - Country:US
Practice Address - Phone:423-246-2411
Practice Address - Fax:423-246-8997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2015-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000264314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0445295Medicaid
TN7440436Medicaid
TN6191590001Medicare NSC
TN445295Medicare Oscar/Certification