1033191044 NPI number — WELLMONT HEALTH SYSTEM

Table of content: (NPI 1033191044)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033191044 NPI number — WELLMONT HEALTH SYSTEM

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
WELLMONT HEALTH SYSTEM
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:
WELLMONT LONESOME PINE HOME HEALTH
Provider Other Organization Name Type Code:
5
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:
1033191044
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2971 FORT HENRY DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KINGSPORT
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37664-4005
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-230-8443
Provider Business Mailing Address Fax Number:
423-245-7874

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
CLOVERLEAF SQUARE
Provider Second Line Business Practice Location Address:
BUILDING G
Provider Business Practice Location Address City Name:
BIG STONE GAP
Provider Business Practice Location Address State Name:
VA
Provider Business Practice Location Address Postal Code:
24219
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
276-523-8668
Provider Business Practice Location Address Fax Number:
276-523-8701
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
HOLLANDER
Authorized Official First Name:
BEVERLY
Authorized Official Middle Name:
A
Authorized Official Title or Position:
DIRECTOR
Authorized Official Telephone Number:
423-230-8475

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  NA , registered in the state of VA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 73861 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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