Basic Information
| Provider Information | |||||||||
| NPI: | 1336606938 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HIGH COUNTRY COMMUNITY HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | HIGH COUNTRY COMMUNITY HEALTH PEDIATRICS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1490 | ||||||||
| Address2: | |||||||||
| City: | BOONE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286071490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8282623886 | ||||||||
| FaxNumber: | 8282654816 | ||||||||
| Practice Location | |||||||||
| Address1: | 1925 N BRIDGE ST STE 101 | ||||||||
| Address2: | |||||||||
| City: | ELKIN | ||||||||
| State: | NC | ||||||||
| PostalCode: | 286212105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3368357337 | ||||||||
| FaxNumber: | 3368357301 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/01/2019 | ||||||||
| LastUpdateDate: | 10/05/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SALTHOUSE | ||||||||
| AuthorizedOfficialFirstName: | ALICE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8282623886 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | HIGH COUNTRY COMMUNITY HEALTH | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/05/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1336606938 | 05 | NC | MEDICAID |