Basic Information
| Provider Information | |||||||||
| NPI: | 1194797472 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WHITE COUNTY COMMUNITY HOSPITAL LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HIGHLANDS MEDICAL CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 100983 | ||||||||
| Address2: | |||||||||
| City: | ATLANTA | ||||||||
| State: | GA | ||||||||
| PostalCode: | 303840983 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 401 SEWELL DR | ||||||||
| Address2: | |||||||||
| City: | SPARTA | ||||||||
| State: | TN | ||||||||
| PostalCode: | 385831223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9317389211 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2006 | ||||||||
| LastUpdateDate: | 09/25/2012 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COFFEY | ||||||||
| AuthorizedOfficialFirstName: | S | ||||||||
| AuthorizedOfficialMiddleName: | RAY | ||||||||
| AuthorizedOfficialTitleorPosition: | VP OF REIMBURSEMENT | ||||||||
| AuthorizedOfficialTelephone: | 6157643009 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | SPARTA HOSPITAL CORPORATION | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273R00000X | 0000000127 | TN | Y | Hospital Units | Psychiatric Unit |
ID Information
| ID | Type | State | Issuer | Description | 621587742 | 01 | CHAMPUS | OTHER |