1386700383 NPI number — FRONTIER HEALTH

Table of content: (NPI 1386700383)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1386700383 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:
WATAUGA BEHAVIORAL HEALTH SERVICES
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:
1386700383
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/12/2018
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:
109 W WATAUGA AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOHNSON CITY
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37604-5621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-232-2600
Provider Business Practice Location Address Fax Number:
423-232-2646
Provider Enumeration Date:
12/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KIDD
Authorized Official First Name:
TERESA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
PRESIDENT AND CEO
Authorized Official Telephone Number:
423-467-3600

Provider Taxonomy Codes

  • Taxonomy code: 251B00000X , with the licence number:  L 214-076-1430 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 251S00000X , with the licence number: L 214-076-1430 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0801X , with the licence number: L 214-076-1430 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR0405X , with the licence number: 325 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 49-4911-1 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".
  • Identifier: SAME AS MEDICARE #S , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".




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