Provider Demographics
NPI:1437537073
Name:SSA JOHNSON CITY ALF, LLC
Entity Type:Organization
Organization Name:SSA JOHNSON CITY ALF, LLC
Other - Org Name:BROADMORE SENIOR LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:D. LEE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:425-474-0425
Mailing Address - Street 1:406 E. MOUNTAIN VIEW ROAD
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601
Mailing Address - Country:US
Mailing Address - Phone:423-282-0300
Mailing Address - Fax:423-282-8117
Practice Address - Street 1:406 E. MOUNTAIN VIEW ROAD
Practice Address - Street 2:
Practice Address - City:JOHNSON CITY
Practice Address - State:TN
Practice Address - Zip Code:37601
Practice Address - Country:US
Practice Address - Phone:423-282-0300
Practice Address - Fax:423-282-8117
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SSA JOHNSON CITY ALF LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-05-15
Last Update Date:2015-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACL000000125310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility