Provider Demographics
NPI:1689603755
Name:OLD FOLKS MISSION CENTER,INC.
Entity Type:Organization
Organization Name:OLD FOLKS MISSION CENTER,INC.
Other - Org Name:MISSION CONVALESCENT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DUANE
Authorized Official - Middle Name:
Authorized Official - Last Name:CHERRY
Authorized Official - Suffix:
Authorized Official - Credentials:NHA
Authorized Official - Phone:731-424-2951
Mailing Address - Street 1:118 GLASS ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38301-4625
Mailing Address - Country:US
Mailing Address - Phone:731-424-2951
Mailing Address - Fax:731-424-7915
Practice Address - Street 1:118 GLASS ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:TN
Practice Address - Zip Code:38301-4625
Practice Address - Country:US
Practice Address - Phone:731-424-2951
Practice Address - Fax:731-424-7915
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-01
Last Update Date:2012-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000175313M00000X
TN0445447314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440140Medicaid
TN445447Medicare Oscar/Certification