Basic Information
| Provider Information | |||||||||
| NPI: | 1902047004 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WELLMONT HEALTH SYSTEM | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | JENKINS PROFEES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1 MEDICAL PARK BLVD | ||||||||
| Address2: | |||||||||
| City: | BRISTOL | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376207430 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4238444711 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 9480 HIGHWAY 805 | ||||||||
| Address2: | |||||||||
| City: | JENKINS | ||||||||
| State: | KY | ||||||||
| PostalCode: | 415378182 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6068322171 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/19/2009 | ||||||||
| LastUpdateDate: | 03/19/2009 | ||||||||
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| AuthorizedOfficialLastName: | KNIGHT | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 4232308200 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 246Z00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Technologists, Technicians & Other Technical Service Providers | Specialist/Technologist, Other |
No ID Information.