Provider Demographics
NPI:1851423792
Name:MITCHELL MANOR INC
Entity Type:Organization
Organization Name:MITCHELL MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-444-2882
Mailing Address - Street 1:152 S COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-3643
Mailing Address - Country:US
Mailing Address - Phone:615-444-2882
Mailing Address - Fax:615-449-9565
Practice Address - Street 1:152 S COLLEGE ST
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-3643
Practice Address - Country:US
Practice Address - Phone:615-444-2882
Practice Address - Fax:615-449-9565
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000300313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0445332Medicaid
TN7440431Medicaid
TN3016165OtherBLUE CROSS BLUESHIELD ID
TN3016165OtherBLUE CROSS BLUESHIELD ID