Provider Demographics
NPI:1881749596
Name:HUMPHREYS COUNTY CARE AND REHABILITATION
Entity type:Organization
Organization Name:HUMPHREYS COUNTY CARE AND REHABILITATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:D
Authorized Official - Last Name:WOLFE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:931-296-2532
Mailing Address - Street 1:104 FORT HILL RD
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:TN
Mailing Address - Zip Code:37185-2128
Mailing Address - Country:US
Mailing Address - Phone:931-296-2532
Mailing Address - Fax:931-296-0829
Practice Address - Street 1:104 FORT HILL RD
Practice Address - Street 2:
Practice Address - City:WAVERLY
Practice Address - State:TN
Practice Address - Zip Code:37185-2128
Practice Address - Country:US
Practice Address - Phone:931-296-2532
Practice Address - Fax:931-296-0829
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-24
Last Update Date:2019-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0135251J00000X
TN0000000135313M00000X, 314000000X
314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No251J00000XAgenciesNursing Care
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440099Medicaid
TN7440099Medicaid