Provider Demographics
NPI:1750360152
Name:IMPERIAL MANOR CONVALESCENT CENTER LLC
Entity type:Organization
Organization Name:IMPERIAL MANOR CONVALESCENT CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SECRETARY
Authorized Official - Prefix:MR
Authorized Official - First Name:KIRK
Authorized Official - Middle Name:F
Authorized Official - Last Name:HEBERT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-250-7100
Mailing Address - Street 1:6 CADILLAC DR
Mailing Address - Street 2:SUITE 310
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5080
Mailing Address - Country:US
Mailing Address - Phone:615-250-7100
Mailing Address - Fax:615-250-7102
Practice Address - Street 1:306 W DUE WEST AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:TN
Practice Address - Zip Code:37115-4511
Practice Address - Country:US
Practice Address - Phone:615-865-5001
Practice Address - Fax:615-865-0321
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:VANGUARD HEALTHCARE, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-01-13
Last Update Date:2009-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000053314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440514Medicaid
TN0445047Medicaid
TN445047Medicare Oscar/Certification