Provider Demographics
NPI:1578510269
Name:HENDERSON RESIDENTIAL, LLC
Entity Type:Organization
Organization Name:HENDERSON RESIDENTIAL, LLC
Other - Org Name:SOUTHERN OAKS ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:TREASURER
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:REIKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-471-1113
Mailing Address - Street 1:558 WHITE AVE
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:TN
Mailing Address - Zip Code:38340-1504
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:558 WHITE AVE
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:TN
Practice Address - Zip Code:38340-1504
Practice Address - Country:US
Practice Address - Phone:731-983-3200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility