Provider Demographics
NPI:1679576847
Name:LIFE CARE AT HOME OF TENNESSEE, INC.
Entity Type:Organization
Organization Name:LIFE CARE AT HOME OF TENNESSEE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF ACCOUNTING
Authorized Official - Prefix:MS
Authorized Official - First Name:STEPHANIE
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-473-5257
Mailing Address - Street 1:3001 KEITH ST NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3713
Mailing Address - Country:US
Mailing Address - Phone:423-473-5256
Mailing Address - Fax:423-559-8356
Practice Address - Street 1:7625 HAMILTON PARK DR
Practice Address - Street 2:STE 16
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1188
Practice Address - Country:US
Practice Address - Phone:423-510-1500
Practice Address - Fax:423-510-1560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-05-23
Last Update Date:2013-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000109251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3062149OtherBLUECROSS BLUESHIELD PROV
TN3062149OtherBLUECROSS BLUESHIELD PROV