1750720058 NPI number — CAMELLIA HOME HEALTH OF SOUTHEAST TENNESSEE, LLC

Table of content: GRACE WOLF MS, CRC, QP, LPCA (NPI 1124524400)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750720058 NPI number — CAMELLIA HOME HEALTH OF SOUTHEAST TENNESSEE, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CAMELLIA HOME HEALTH OF SOUTHEAST TENNESSEE, 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:
1750720058
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
135 MAYFAIR RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HATTIESBURG
Provider Business Mailing Address State Name:
MS
Provider Business Mailing Address Postal Code:
39402-1464
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
601-544-2903
Provider Business Mailing Address Fax Number:
601-579-6991

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6711 MOUNTAIN VIEW RD
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
OOLTEWAH
Provider Business Practice Location Address State Name:
TN
Provider Business Practice Location Address Postal Code:
37363-6668
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-414-3017
Provider Business Practice Location Address Fax Number:
423-238-1199
Provider Enumeration Date:
06/19/2013

Additional Information

Authorized Official

Authorized Official Last Name:
PAYNE
Authorized Official First Name:
WILFORD
Authorized Official Middle Name:
A
Authorized Official Title or Position:
PRESIDENT / CEO
Authorized Official Telephone Number:
601-544-2903

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X , with the licence number:  107 , 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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