Basic Information
| Provider Information | |||||||||
| NPI: | 1891952248 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | JELLICO COMMUNITY HOSPITAL, INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | CARE PLUS REHAB | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 188 HOSPITAL LN | ||||||||
| Address2: | |||||||||
| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237841272 | ||||||||
| FaxNumber: | 7237841136 | ||||||||
| Practice Location | |||||||||
| Address1: | 998 S HIGHWAY 25 W | ||||||||
| Address2: | |||||||||
| City: | WILLIAMSBURG | ||||||||
| State: | KY | ||||||||
| PostalCode: | 407691692 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6065491183 | ||||||||
| FaxNumber: | 6065498107 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/21/2008 | ||||||||
| LastUpdateDate: | 03/10/2016 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | 12/06/2011 | ||||||||
| NPIReactivationDate: | 05/22/2012 | ||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GHULAM | ||||||||
| AuthorizedOfficialFirstName: | EVELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CONTROLLER | ||||||||
| AuthorizedOfficialTelephone: | 4237841334 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 273Y00000X | Y | Hospital Units | Rehabilitation Unit |
ID Information
| ID | Type | State | Issuer | Description | 01620848 | 05 | KY | MEDICAID | 0440180 | 05 | TN | MEDICAID |