Provider Demographics
NPI:1467761841
Name:SWEETWATER HOME FOR SENIORS
Entity Type:Organization
Organization Name:SWEETWATER HOME FOR SENIORS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SAMUEL
Authorized Official - Middle Name:ALEXANDER
Authorized Official - Last Name:BEVERLEY
Authorized Official - Suffix:III
Authorized Official - Credentials:MBA
Authorized Official - Phone:423-337-9742
Mailing Address - Street 1:245 BUTLER DR
Mailing Address - Street 2:
Mailing Address - City:SWEETWATER
Mailing Address - State:TN
Mailing Address - Zip Code:37874-1441
Mailing Address - Country:US
Mailing Address - Phone:423-337-9742
Mailing Address - Fax:423-836-9095
Practice Address - Street 1:245 BUTLER DR
Practice Address - Street 2:
Practice Address - City:SWEETWATER
Practice Address - State:TN
Practice Address - Zip Code:37874-1441
Practice Address - Country:US
Practice Address - Phone:423-337-9742
Practice Address - Fax:423-836-9095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-01
Last Update Date:2010-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACL000000291310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH4451113Medicaid