1679741532 NPI number — HOLSTON REGIONAL COMPREHENSIVE MEDICINE

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1679741532 NPI number — HOLSTON REGIONAL COMPREHENSIVE MEDICINE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
HOLSTON REGIONAL COMPREHENSIVE MEDICINE
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:
1679741532
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1303 E CENTER ST
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:
37664-2444
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
423-384-2820
Provider Business Mailing Address Fax Number:
423-239-9649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1303 E CENTER ST
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:
37664-2444
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
423-384-9266
Provider Business Practice Location Address Fax Number:
423-239-9649
Provider Enumeration Date:
02/13/2008

Additional Information

Authorized Official

Authorized Official Last Name:
TASKER
Authorized Official First Name:
JPHN
Authorized Official Middle Name:
JAMES
Authorized Official Title or Position:
DOCTOR
Authorized Official Telephone Number:
423-384-9266

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 6205721 , issued by the state of ( VA ) . This identifiers is of the category "MEDICAID".




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