Provider Demographics
NPI:1811218324
Name:CHRISTIAN CARE CENTER OF RUTHERFORD COUNTY LLC
Entity Type:Organization
Organization Name:CHRISTIAN CARE CENTER OF RUTHERFORD COUNTY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:RISK CONSULTANT
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CAWOOD-GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-975-5455
Mailing Address - Street 1:2020 NORTHPARK
Mailing Address - Street 2:SUITE 2D
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-3127
Mailing Address - Country:US
Mailing Address - Phone:423-975-5455
Mailing Address - Fax:423-975-5405
Practice Address - Street 1:202 ENON SPRINGS ROAD EAST
Practice Address - Street 2:
Practice Address - City:SMYRNA
Practice Address - State:TN
Practice Address - Zip Code:37167
Practice Address - Country:US
Practice Address - Phone:615-459-5600
Practice Address - Fax:615-459-7022
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-18
Last Update Date:2012-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000221313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0445502Medicaid
TN7440610Medicaid
TN0445502Medicaid
6628300001Medicare NSC