Basic Information
Provider Information | |||||||||
NPI: | 1922437466 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MOUNTAIN STATES HEALTH ALLIANCE | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | UNICOI COUNTY NURSING HOME | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 311 PRINCETON RD STE 1 | ||||||||
Address2: |   | ||||||||
City: | JOHNSON CITY | ||||||||
State: | TN | ||||||||
PostalCode: | 376012026 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237433141 | ||||||||
FaxNumber: | 4237431244 | ||||||||
Practice Location | |||||||||
Address1: | 100 GREENWAY CIR | ||||||||
Address2: |   | ||||||||
City: | ERWIN | ||||||||
State: | TN | ||||||||
PostalCode: | 376502177 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4237433141 | ||||||||
FaxNumber: | 4237431244 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/05/2013 | ||||||||
LastUpdateDate: | 03/28/2018 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KRUTAK | ||||||||
AuthorizedOfficialFirstName: | MARY | ||||||||
AuthorizedOfficialMiddleName: | LYNN | ||||||||
AuthorizedOfficialTitleorPosition: | EVP/CFO | ||||||||
AuthorizedOfficialTelephone: | 4233023423 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MRS. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X |   |   | N |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 0445077 | 01 | TN | MEDICAID SNF | OTHER | 7440197 | 01 | TN | MEDICAID ICF | OTHER |