Provider Demographics
NPI:1528221587
Name:SHADYBROOK
Entity Type:Organization
Organization Name:SHADYBROOK
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-638-3926
Mailing Address - Street 1:100 PENNSYLVANIA AVE
Mailing Address - Street 2:
Mailing Address - City:GREENEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37743-4624
Mailing Address - Country:US
Mailing Address - Phone:423-638-3926
Mailing Address - Fax:423-638-1105
Practice Address - Street 1:100 PENNSYLVANIA AVE
Practice Address - Street 2:
Practice Address - City:GREENEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37743-4624
Practice Address - Country:US
Practice Address - Phone:423-638-3926
Practice Address - Fax:423-638-1105
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-09
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL000000015032315P00000X
TNL000000017005315P00000X
315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7447099OtherICF-MR