Basic Information
| Provider Information | |||||||||
| NPI: | 1407154800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JELLICO COMMUNITY HOSPITAL, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CARE PLUS CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 188 HOSPITAL LANE | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237847252 | ||||||||
| FaxNumber: | 4237841136 | ||||||||
| Practice Location | |||||||||
| Address1: | 998 SOUTH HIGHWAY 25W | ||||||||
| Address2: | |||||||||
| City: | WILLAIMSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065491183 | ||||||||
| FaxNumber: | 6065498107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/09/2011 | ||||||||
| LastUpdateDate: | 03/10/2016 | ||||||||
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| AuthorizedOfficialLastName: | GHULAM | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4237841334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 3007739 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 3004431 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | 3002560 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363AM0700X | PA071 | KY | N | 193200000X MULTI-SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | Medical | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.