Provider Demographics
NPI:1932183134
Name:CHRISTIAN CARE CENTER OF SPRINGFIELD LLC
Entity Type:Organization
Organization Name:CHRISTIAN CARE CENTER OF SPRINGFIELD LLC
Other - Org Name:CHRISTIAN CARE CENTER OF SPRINGFIELD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JIMMY
Authorized Official - Middle Name:R
Authorized Official - Last Name:LEWIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-975-5455
Mailing Address - Street 1:704 5TH AVE E
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:TN
Mailing Address - Zip Code:37172-2604
Mailing Address - Country:US
Mailing Address - Phone:615-384-7977
Mailing Address - Fax:615-382-1023
Practice Address - Street 1:704 5TH AVE E
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:TN
Practice Address - Zip Code:37172-2604
Practice Address - Country:US
Practice Address - Phone:615-384-7977
Practice Address - Fax:615-382-1023
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-01
Last Update Date:2008-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000214313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0445480Medicaid
TN7440061Medicaid
5769250001Medicare NSC
TN7440061Medicaid