Provider Demographics
NPI:1780609651
Name:MATURECARE OF STANDIFER PLACE LLC
Entity type:Organization
Organization Name:MATURECARE OF STANDIFER PLACE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:B
Authorized Official - Last Name:MORTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-893-7523
Mailing Address - Street 1:2626 WALKER RD
Mailing Address - Street 2:
Mailing Address - City:CHATTANOOGA
Mailing Address - State:TN
Mailing Address - Zip Code:37421-1116
Mailing Address - Country:US
Mailing Address - Phone:423-490-1599
Mailing Address - Fax:
Practice Address - Street 1:2626 WALKER RD
Practice Address - Street 2:
Practice Address - City:CHATTANOOGA
Practice Address - State:TN
Practice Address - Zip Code:37421-1116
Practice Address - Country:US
Practice Address - Phone:423-490-1599
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SALT FOUNDATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-13
Last Update Date:2020-07-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
253Z00000X, 261QA0600X, 310400000X
TN103314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No253Z00000XAgenciesIn Home Supportive Care
No261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
7544368OtherAETNA
702010155OtherCARITEN
01400793OtherCIGNA
TN3151760OtherBCBS
TN0445111Medicaid
TN7440081Medicaid
702010155OtherCARITEN