Provider Demographics
NPI:1366432031
Name:CLC OF RIPLEY, LLC
Entity type:Organization
Organization Name:CLC OF RIPLEY, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:DOUGLAS
Authorized Official - Middle Name:M
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:662-680-3148
Mailing Address - Street 1:215 LACKEY LN
Mailing Address - Street 2:
Mailing Address - City:RIPLEY
Mailing Address - State:TN
Mailing Address - Zip Code:38063-1619
Mailing Address - Country:US
Mailing Address - Phone:731-635-5100
Mailing Address - Fax:731-635-5184
Practice Address - Street 1:215 LACKEY LN
Practice Address - Street 2:
Practice Address - City:RIPLEY
Practice Address - State:TN
Practice Address - Zip Code:38063-1619
Practice Address - Country:US
Practice Address - Phone:731-635-5100
Practice Address - Fax:731-635-5184
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-25
Last Update Date:2008-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000154314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN744-0559Medicaid
TN44-5354Medicare ID - Type Unspecified