Provider Demographics
NPI:1801884010
Name:BRADLEY COUNTY NURSING HOME
Entity type:Organization
Organization Name:BRADLEY COUNTY NURSING HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:H
Authorized Official - Last Name:NEWCOMB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-472-7116
Mailing Address - Street 1:2910 PEERLESS RD NW
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37312-3742
Mailing Address - Country:US
Mailing Address - Phone:423-472-7116
Mailing Address - Fax:
Practice Address - Street 1:2910 PEERLESS RD NW
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:TN
Practice Address - Zip Code:37312-3742
Practice Address - Country:US
Practice Address - Phone:423-472-7116
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-11
Last Update Date:2010-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0345040001OtherDEMERC/PALMETTO
TN7440017Medicaid
TN0345040001OtherDME MAC JURISDICTION C
TN0445141Medicaid
TN7440017Medicaid
TN0445141Medicaid
TN0345040001OtherDEMERC/PALMETTO