Basic Information
| Provider Information | |||||||||
| NPI: | 1396717963 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MOUNTAIN STATES HEALTH ALLIANCE | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | BALLAD HEALTH HOMECARE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 311 PRINCETON RD STE 1 | ||||||||
| Address2: | |||||||||
| City: | JOHNSON CITY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376012026 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237875030 | ||||||||
| FaxNumber: | 4237875009 | ||||||||
| Practice Location | |||||||||
| Address1: | 1410 TUSCULUM BLVD STE 1600 | ||||||||
| Address2: | |||||||||
| City: | GREENEVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377454286 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237875030 | ||||||||
| FaxNumber: | 4237875009 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/07/2006 | ||||||||
| LastUpdateDate: | 04/01/2019 | ||||||||
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| AuthorizedOfficialLastName: | KRUTAK | ||||||||
| AuthorizedOfficialFirstName: | MARY | ||||||||
| AuthorizedOfficialMiddleName: | LYNN | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
| AuthorizedOfficialTelephone: | 4233023423 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251E00000X | 0000000088 | TN | Y | Agencies | Home Health |
ID Information
| ID | Type | State | Issuer | Description | 044-7428 | 05 | TN | MEDICAID |