Basic Information
| Provider Information | |||||||||
| NPI: | 1023022084 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | DAYSPRING HEALTH INC | ||||||||
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| OtherOrganizationName: | DAYSPRING JELLICO | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 S MAIN ST | ||||||||
| Address2: | P.O. BOX 540 | ||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377622154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237848492 | ||||||||
| FaxNumber: | 4237848358 | ||||||||
| Practice Location | |||||||||
| Address1: | 550 SUNSET TRL | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237845771 | ||||||||
| FaxNumber: | 4237846185 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/27/2006 | ||||||||
| LastUpdateDate: | 03/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | THOMAS | ||||||||
| AuthorizedOfficialFirstName: | GEOGY | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4237848492 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | MD | ||||||||
| NPICertificationDate: | 03/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | 43450 | TN | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 261QF0400X | 441853 | TN | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 204123 | 01 | TN | BLACK LUNG | OTHER | 4447931 | 05 | TN | MEDICAID | 65903650 | 05 | KY | MEDICAID | 0980730 | 01 | TN | UMWA | OTHER |