Basic Information
Provider Information | |||||||||
NPI: | 1336635192 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOUNTAIN STATES HEALTH ALLIANCE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | BALLAD HEALTH HOSPICE | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 311 PRINCETON RD STE 1 | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376012026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2766194500 | ||||||||
FaxNumber: | 4238446379 | ||||||||
Practice Location | |||||||||
Address1: | 611 CAMPUS DR STE 500 | ||||||||
Address2: |   | ||||||||
City: | ABINGDON | ||||||||
State: | VA | ||||||||
PostalCode: | 242109701 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2766194500 | ||||||||
FaxNumber: | 4238446379 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/05/2018 | ||||||||
LastUpdateDate: | 06/24/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KRUTAK | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
AuthorizedOfficialTelephone: | 4233023423 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 06/24/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 315D00000X |   |   | Y |   | Nursing & Custodial Care Facilities | Hospice, Inpatient |   |
No ID Information.