Provider Demographics
NPI:1568564425
Name:PRIVATE SENIOR PROVIDERS ETP LLC
Entity Type:Organization
Organization Name:PRIVATE SENIOR PROVIDERS ETP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:SHERMAN
Authorized Official - Last Name:GILLESPIE
Authorized Official - Suffix:
Authorized Official - Credentials:HOME HEALTH AIDE
Authorized Official - Phone:901-315-8619
Mailing Address - Street 1:PO BOX 770193
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38177-0193
Mailing Address - Country:US
Mailing Address - Phone:901-315-8619
Mailing Address - Fax:901-761-2907
Practice Address - Street 1:234 PANDORA ST
Practice Address - Street 2:CO/BRENDA THOMPSON
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-2855
Practice Address - Country:US
Practice Address - Phone:901-315-8619
Practice Address - Fax:901-763-2907
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-02
Last Update Date:2007-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization