Basic Information
| Provider Information | |||||||||
| NPI: | 1992752745 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | TALLASSEE HEALTH AND REHABILITATION, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2639 GILMER AVE | ||||||||
| Address2: | P. O. BOX 780277 | ||||||||
| City: | TALLASSEE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360787231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342833975 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2639 GILMER AVE | ||||||||
| Address2: | |||||||||
| City: | TALLASSEE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 360787231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3342833975 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 05/27/2006 | ||||||||
| LastUpdateDate: | 10/12/2020 | ||||||||
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| AuthorizedOfficialLastName: | LONG | ||||||||
| AuthorizedOfficialFirstName: | PHILLIP | ||||||||
| AuthorizedOfficialMiddleName: | CODY | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2053913600 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 10/12/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4753620S | 05 | AL | MEDICAID | 014229 | 01 | AL | BCBS ID | OTHER |