1265597280 NPI number — FRONTIER HEALTH

Table of content: (NPI 1265597280)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1265597280 NPI number — FRONTIER HEALTH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FRONTIER HEALTH
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:
ROLLER RUSS RESIDENCE FOR INDEPENDENT LIVING
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:
1265597280
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:
PO BOX 9054
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAY
Provider Business Mailing Address State Name:
TN
Provider Business Mailing Address Postal Code:
37615-9054
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-467-3600
Provider Business Mailing Address Fax Number:
423-467-3644

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2221 MEMORIAL CT
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KINGSPORT
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37664-3339
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-245-1121
Provider Business Practice Location Address Fax Number:
423-467-3644
Provider Enumeration Date:
12/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
VARNEY
Authorized Official First Name:
E
Authorized Official Middle Name:
DOUGLAS
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
423-467-3600

Provider Taxonomy Codes

  • Taxonomy code: 320800000X , with the licence number:  L 219-076-1426 , 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)





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