1528627791 NPI number — MARYVILLE FAIRPARK OPCO LLC

Table of content: (NPI 1528627791)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1528627791 NPI number — MARYVILLE FAIRPARK OPCO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MARYVILLE FAIRPARK OPCO LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
FAIRPARK HEALTH AND REHABILITATION
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1528627791
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/09/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2100 CHEROKEE RIDGE WAY STE 100
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOUISVILLE
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
40205-1600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
502-667-8150
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
307 N 5TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MARYVILLE
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37804-2921
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
865-983-0261
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
06/11/2019

Additional Information

Authorized Official

Authorized Official Last Name:
VUJANOVIC
Authorized Official First Name:
MICK
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
502-667-8150

Provider Taxonomy Codes

  • Taxonomy code: 314000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 385H00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)





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