1093920787 NPI number — FENTRESS HEALTH SYSTEMS, LLC

Table of content: (NPI 1093920787)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093920787 NPI number — FENTRESS HEALTH SYSTEMS, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FENTRESS HEALTH SYSTEMS, LLC
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:
Provider Other Organization Name Type Code:
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:
1093920787
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/24/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 51923
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
KNOXVILLE
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37950-1923
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
865-531-6070
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
208 W CENTRAL AVENUE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JAMESTOWN
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
38556
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
931-752-2273
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
05/14/2007

Additional Information

Authorized Official

Authorized Official Last Name:
ALLRED
Authorized Official First Name:
BALEY
Authorized Official Middle Name:
F
Authorized Official Title or Position:
CHARIMAN OF THE BOARD
Authorized Official Telephone Number:
931-752-2273

Provider Taxonomy Codes

  • Taxonomy code: 261QM1200X , with the licence number:  34 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 3790001 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: TN0101 . This is a "AMERICHOICE" identifier . This identifiers is of the category "OTHER".




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