Provider Demographics
NPI:1659707743
Name:FAYETTEVILLE HEALTHCARE, LLC
Entity Type:Organization
Organization Name:FAYETTEVILLE HEALTHCARE, LLC
Other - Org Name:FAYETTEVILLE HEALTH AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-478-5953
Mailing Address - Street 1:4081 THORNTON TAYLOR PKWY
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37334-2674
Mailing Address - Country:US
Mailing Address - Phone:931-433-9973
Mailing Address - Fax:
Practice Address - Street 1:4081 THORNTON TAYLOR PKWY
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:TN
Practice Address - Zip Code:37334-2674
Practice Address - Country:US
Practice Address - Phone:931-433-9773
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-19
Last Update Date:2019-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440356Medicaid
TN0445320Medicaid