Provider Demographics
NPI:1619274644
Name:SOUTHERN MANOR LIVING CENTERS, LLC
Entity Type:Organization
Organization Name:SOUTHERN MANOR LIVING CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERYL
Authorized Official - Middle Name:
Authorized Official - Last Name:PENDERGRASS
Authorized Official - Suffix:
Authorized Official - Credentials:MSN
Authorized Official - Phone:931-433-5000
Mailing Address - Street 1:115 MEDICAL CENTER BLVD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-2689
Mailing Address - Country:US
Mailing Address - Phone:931-433-5000
Mailing Address - Fax:931-433-6908
Practice Address - Street 1:115 MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2689
Practice Address - Country:US
Practice Address - Phone:931-433-5000
Practice Address - Fax:931-433-6908
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-02-28
Last Update Date:2011-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACL0000000215310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility