Provider Demographics
NPI:1396213492
Name:FOREST AVENUE OPCO, LLC
Entity Type:Organization
Organization Name:FOREST AVENUE OPCO, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:THOMAS
Authorized Official - Last Name:FICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-250-7100
Mailing Address - Street 1:9020 OVERLOOK BLVD STE 202
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-2755
Mailing Address - Country:US
Mailing Address - Phone:615-250-7100
Mailing Address - Fax:615-250-7101
Practice Address - Street 1:1116 FOREST AVE
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39206-3216
Practice Address - Country:US
Practice Address - Phone:601-366-6461
Practice Address - Fax:601-362-4041
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-11-06
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility