Basic Information
| Provider Information | |||||||||
| NPI: | 1396912838 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | UNICOI COUNTY OUTPATIENT REHAB | ||||||||
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| Mailing Information | |||||||||
| Address1: | 100 GREENWAY CIR | ||||||||
| Address2: | |||||||||
| City: | ERWIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376502177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237433141 | ||||||||
| FaxNumber: | 4237432887 | ||||||||
| Practice Location | |||||||||
| Address1: | 100 GREENWAY CIR | ||||||||
| Address2: | |||||||||
| City: | ERWIN | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376502177 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237433141 | ||||||||
| FaxNumber: | 4237432887 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/14/2008 | ||||||||
| LastUpdateDate: | 05/14/2008 | ||||||||
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| AuthorizedOfficialLastName: | PATE | ||||||||
| AuthorizedOfficialFirstName: | JIMMY | ||||||||
| AuthorizedOfficialMiddleName: | S | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4237433141 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | UNICOI COUNTY MEMORIAL HOSPITAL INC | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 282N00000X | 0000000119 | TN | Y | Hospitals | General Acute Care Hospital |
ID Information
| ID | Type | State | Issuer | Description | 4088769 | 01 | TN | BLUE CROSS AND BLUE SHIELD OF TENNESSEE | OTHER |