Provider Demographics
NPI:1417308172
Name:MINNOLA RESIDENTIAL CARE SERVICES,LLC
Entity Type:Organization
Organization Name:MINNOLA RESIDENTIAL CARE SERVICES,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:TERETHRA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARRIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:901-857-6635
Mailing Address - Street 1:4264 GENYTH AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38128-3212
Mailing Address - Country:US
Mailing Address - Phone:901-857-6635
Mailing Address - Fax:
Practice Address - Street 1:4264 GENYTH AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-3212
Practice Address - Country:US
Practice Address - Phone:901-857-6635
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-06-23
Last Update Date:2016-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN1000000018260251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNQ021859Medicaid