Provider Demographics
NPI:1831230762
Name:MATURECARE OF STANDIFER PLACE LLC
Entity type:Organization
Organization Name:MATURECARE OF STANDIFER PLACE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:STRAWN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-490-1599
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:
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:2007-02-12
Last Update Date:2008-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
4041443OtherPPO