Provider Demographics
NPI:1669534566
Name:LAURELBROOK SANITARIUM AND SCHOOL
Entity type:Organization
Organization Name:LAURELBROOK SANITARIUM AND SCHOOL
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KEITH
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-775-0771
Mailing Address - Street 1:114 CAMPUS DRIVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:TN
Mailing Address - Zip Code:37321-4635
Mailing Address - Country:US
Mailing Address - Phone:423-775-0771
Mailing Address - Fax:423-775-6346
Practice Address - Street 1:200 SANITARIUM CIRCLE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:TN
Practice Address - Zip Code:37321-4635
Practice Address - Country:US
Practice Address - Phone:423-775-0771
Practice Address - Fax:423-834-9059
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-15
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN00000000208313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440119Medicaid