Provider Demographics
NPI:1497807119
Name:CROCKETT COUNTY NURSING HOME, INC.
Entity Type:Organization
Organization Name:CROCKETT COUNTY NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:BARBARA
Authorized Official - Middle Name:
Authorized Official - Last Name:PARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-696-4541
Mailing Address - Street 1:PO BOX 367
Mailing Address - Street 2:
Mailing Address - City:ALAMO
Mailing Address - State:TN
Mailing Address - Zip Code:38001-0367
Mailing Address - Country:US
Mailing Address - Phone:731-696-4541
Mailing Address - Fax:731-696-4948
Practice Address - Street 1:580 WEST MAIN STREET
Practice Address - Street 2:
Practice Address - City:ALAMO
Practice Address - State:TN
Practice Address - Zip Code:38001-0367
Practice Address - Country:US
Practice Address - Phone:731-696-4541
Practice Address - Fax:731-696-4948
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000029313M00000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
No314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440325Medicaid
TN0445467OtherMEDICAID LEVEL II
TN7440325Medicaid