Basic Information
| Provider Information | |||||||||
| NPI: | 1003944794 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | SMOKY MOUNTAIN CENTER FOR MH DD SAS | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SMOKY MOUNTAIN CENTER | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 TEPTAL TER | ||||||||
| Address2: | |||||||||
| City: | BRYSON CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287135479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284885752 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 100 TEPTAL TER | ||||||||
| Address2: | |||||||||
| City: | BRYSON CITY | ||||||||
| State: | NC | ||||||||
| PostalCode: | 287135479 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8284885752 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | MCDEVITT | ||||||||
| AuthorizedOfficialFirstName: | THOMAS | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | AREA DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 8285865501 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 5901891 | 05 | NC | MEDICAID |