Basic Information
| Provider Information | |||||||||
| NPI: | 1871631804 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DAYSPRING HEALTH INC | ||||||||
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| OtherOrganizationName: | DAYSPRING DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 402 CUMBERLAND AVE | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 40769 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065492656 | ||||||||
| FaxNumber: | 6065492855 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/02/2007 | ||||||||
| LastUpdateDate: | 12/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | HARRIS | ||||||||
| AuthorizedOfficialFirstName: | JOHN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 4237848492 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 12/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 207V00000X | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Obstetrics & Gynecology | 363A00000X | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Physician Assistant | 363L00000X | KY | N | 193400000X MULTIPLE SINGLE SPECIALTY GROUP | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 261QF0400X | 181827 | KY | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 31000946 | 05 | KY | MEDICAID | 18C7 | 01 | KY | ANTHEM BCBS | OTHER | 7890332500 | 01 | KY | NP GROUP FOR KY MEDICAID | OTHER | 206742 | 01 | KY | BLACK LUNG | OTHER |