Basic Information
| Provider Information | |||||||||
| NPI: | 1992253025 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HCC OF JELLICO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17304 PRESTON RD | ||||||||
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| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752525618 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9729343200 | ||||||||
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| Practice Location | |||||||||
| Address1: | 188 HOSPITAL LN | ||||||||
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| City: | JELLICO | ||||||||
| State: | TN | ||||||||
| PostalCode: | 377624400 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4237847252 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/19/2016 | ||||||||
| LastUpdateDate: | 09/19/2016 | ||||||||
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| AuthorizedOfficialLastName: | WEISS | ||||||||
| AuthorizedOfficialFirstName: | RON | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9729343200 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Internal Medicine |
No ID Information.