Provider Demographics
NPI:1972181998
Name:CHRISTIAN CARE CENTER OF BOLIVAR LLC
Entity Type:Organization
Organization Name:CHRISTIAN CARE CENTER OF BOLIVAR LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DELEGATED OFFICIAL, REGISTRATIONS O
Authorized Official - Prefix:MS
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:423-557-6116
Mailing Address - Street 1:2020 NORTHPARK DR STE 2D
Mailing Address - Street 2:
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:423-390-0743
Practice Address - Street 1:10160 HIGHWAY 64W
Practice Address - Street 2:
Practice Address - City:BOLIVAR
Practice Address - State:TN
Practice Address - Zip Code:38008
Practice Address - Country:US
Practice Address - Phone:423-975-5455
Practice Address - Fax:423-390-0743
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-31
Last Update Date:2022-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility