Provider Demographics
NPI:1861664955
Name:REELFOOT OPERATOR LLC
Entity Type:Organization
Organization Name:REELFOOT OPERATOR LLC
Other - Org Name:REELFOOT MANOR HEALTH AND REHAB
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:A
Authorized Official - Last Name:CHAMBERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:731-253-6681
Mailing Address - Street 1:1034 REELFOOT ST
Mailing Address - Street 2:
Mailing Address - City:TIPTONVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38079-1607
Mailing Address - Country:US
Mailing Address - Phone:731-253-6681
Mailing Address - Fax:731-253-8014
Practice Address - Street 1:1034 REELFOOT ST
Practice Address - Street 2:
Practice Address - City:TIPTONVILLE
Practice Address - State:TN
Practice Address - Zip Code:38079-1607
Practice Address - Country:US
Practice Address - Phone:731-253-6681
Practice Address - Fax:731-253-8014
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-03-28
Last Update Date:2015-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000151314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440374 (ICF)Medicaid
TN0445285 (SNF)Medicaid
445285Medicare Oscar/Certification