Provider Demographics
NPI:1629258546
Name:CORDOVA HEALTHCARE, LLC
Entity Type:Organization
Organization Name:CORDOVA HEALTHCARE, LLC
Other - Org Name:GRACE HEALTHCARE OF CORDOVA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CRAIG
Authorized Official - Middle Name:D
Authorized Official - Last Name:TAYLOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-308-1845
Mailing Address - Street 1:955 N GERMANTOWN PKWY
Mailing Address - Street 2:
Mailing Address - City:CORDOVA
Mailing Address - State:TN
Mailing Address - Zip Code:38018-6215
Mailing Address - Country:US
Mailing Address - Phone:901-754-1393
Mailing Address - Fax:336-433-7468
Practice Address - Street 1:955 N GERMANTOWN PKWY
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38018-6215
Practice Address - Country:US
Practice Address - Phone:901-754-1393
Practice Address - Fax:336-433-7468
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-08
Last Update Date:2014-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000238314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0445218Medicaid
TN7440486Medicaid
TN445218Medicare Oscar/Certification