Provider Demographics
NPI:1609264142
Name:PRESTIGE CARE HOME
Entity Type:Organization
Organization Name:PRESTIGE CARE HOME
Other - Org Name:ANGELIC VISITS SENIOR SUPPORT AGENCY
Other - Org Type:Other Name
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHIRLEY
Authorized Official - Middle Name:
Authorized Official - Last Name:SPILLER-JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:901-281-8292
Mailing Address - Street 1:2051 MONTREAT DR
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38134-6613
Mailing Address - Country:US
Mailing Address - Phone:901-281-8292
Mailing Address - Fax:901-388-7366
Practice Address - Street 1:2051 MONTREAT DR
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38134-6613
Practice Address - Country:US
Practice Address - Phone:901-281-8292
Practice Address - Fax:901-388-7366
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PRESTIGE CARE HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000565251E00000X, 310400000X, 311500000X, 311Z00000X, 311ZA0620X, 385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No251E00000XAgenciesHome Health
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNH445488Medicaid