Provider Demographics
NPI:1891032710
Name:SOUTHERN MANOR LIVING CENTERS OF LEBANON, LLC
Entity Type:Organization
Organization Name:SOUTHERN MANOR LIVING CENTERS OF LEBANON, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:BRADSHAW
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:615-443-7929
Mailing Address - Street 1:900 COLES FERRY PIKE
Mailing Address - Street 2:
Mailing Address - City:LEBANON
Mailing Address - State:TN
Mailing Address - Zip Code:37087-5677
Mailing Address - Country:US
Mailing Address - Phone:615-443-7929
Mailing Address - Fax:615-443-7502
Practice Address - Street 1:900 COLES FERRY PIKE
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:TN
Practice Address - Zip Code:37087-5677
Practice Address - Country:US
Practice Address - Phone:615-443-7929
Practice Address - Fax:615-443-7502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2013-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNACL0000000158310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility