Provider Demographics
NPI:1922004811
Name:CLOVERDALE HEALTH CARE, INC.
Entity type:Organization
Organization Name:CLOVERDALE HEALTH CARE, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KRISTY
Authorized Official - Middle Name:A
Authorized Official - Last Name:JONES
Authorized Official - Suffix:
Authorized Official - Credentials:LNHA
Authorized Official - Phone:256-259-1505
Mailing Address - Street 1:412 W CLOVERDALE RD
Mailing Address - Street 2:
Mailing Address - City:SCOTTSBORO
Mailing Address - State:AL
Mailing Address - Zip Code:35768-4264
Mailing Address - Country:US
Mailing Address - Phone:256-259-1505
Mailing Address - Fax:256-259-4279
Practice Address - Street 1:412 W CLOVERDALE RD
Practice Address - Street 2:
Practice Address - City:SCOTTSBORO
Practice Address - State:AL
Practice Address - Zip Code:35768-4264
Practice Address - Country:US
Practice Address - Phone:256-259-1505
Practice Address - Fax:256-259-4279
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-24
Last Update Date:2017-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL10541314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL4753350SMedicaid
AL011620OtherBLUE CROSS BLUE SHIELD AL
AL011620OtherBLUE CROSS BLUE SHIELD AL
AL4753350SMedicaid
AL=========OtherFEDERAL TAX ID NUMBER