Provider Demographics
NPI:1942202171
Name:BRAKEBILL NURSING HOME, INC.
Entity Type:Organization
Organization Name:BRAKEBILL NURSING HOME, INC.
Other - Org Name:BRAKEBILL NURSING AND REHABILITATION CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:WILKERSON
Authorized Official - Suffix:
Authorized Official - Credentials:CPA
Authorized Official - Phone:865-584-3902
Mailing Address - Street 1:5837 LYONS VIEW PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37919-6474
Mailing Address - Country:US
Mailing Address - Phone:865-584-3902
Mailing Address - Fax:865-584-2122
Practice Address - Street 1:5837 LYONS VIEW PIKE
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37919-6474
Practice Address - Country:US
Practice Address - Phone:865-584-3902
Practice Address - Fax:865-584-2122
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRAKEBILL NURSING HOME, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-01
Last Update Date:2007-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000141313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1000662OtherBCBS
TN313M00000XMedicaid