1023022084 NPI number — DAYSPRING HEALTH INC

Table of content: (NPI 1023022084)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023022084 NPI number — DAYSPRING HEALTH INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DAYSPRING HEALTH INC
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:
DAYSPRING JELLICO
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:
1023022084
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
107 S MAIN ST
Provider Second Line Business Mailing Address:
P.O. BOX 540
Provider Business Mailing Address City Name:
JELLICO
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37762-2154
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-784-8492
Provider Business Mailing Address Fax Number:
423-784-8358

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 SUNSET TRL
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JELLICO
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37762
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-784-5771
Provider Business Practice Location Address Fax Number:
423-784-6185
Provider Enumeration Date:
07/27/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THOMAS
Authorized Official First Name:
GEOGY
Authorized Official Middle Name:
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
423-784-8492

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207V00000X , with the licence number: 43450 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , with the licence number: 441853 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363A00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 204123 . This is a "BLACK LUNG" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4447931 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 65903650 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".
  • Identifier: 0980730 . This is a "UMWA" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".