Provider Demographics
NPI:1437143492
Name:EXTENDICARE OF WEST TENN
Entity Type:Organization
Organization Name:EXTENDICARE OF WEST TENN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARSHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:731-668-1372
Mailing Address - Street 1:90 DIRECTORS ROW
Mailing Address - Street 2:P O BOX 3482
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-2345
Mailing Address - Country:US
Mailing Address - Phone:731-668-1372
Mailing Address - Fax:731-664-9919
Practice Address - Street 1:90 DIRECTORS ROW
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38305-2345
Practice Address - Country:US
Practice Address - Phone:731-668-1372
Practice Address - Fax:731-664-9919
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000120251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN447284Medicare ID - Type UnspecifiedMEDICARE PROVIDER