Basic Information
| Provider Information | |||||||||
| NPI: | 1770790065 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAYSPRING HEALTH INC | ||||||||
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| OtherOrganizationName: | DAYSPRING FAMILY HEALTH CENTER | ||||||||
| OtherOrganizationType: | 4 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 107 S MAIN ST | ||||||||
| Address2: | P.O. BOX 540 | ||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377622154 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237848492 | ||||||||
| FaxNumber: | 4237848358 | ||||||||
| Practice Location | |||||||||
| Address1: | 107 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 37762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237848492 | ||||||||
| FaxNumber: | 4237848358 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/17/2007 | ||||||||
| LastUpdateDate: | 10/23/2019 | ||||||||
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| AuthorizedOfficialLastName: | WATT | ||||||||
| AuthorizedOfficialFirstName: | W | ||||||||
| AuthorizedOfficialMiddleName: | MARK | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 4237848492 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | CEO | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363A00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 207Q00000X | Y | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.