MEDICARE: MOBILE HEALTH VAN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QC1500X	Community Health Clinic/Center

General Provider Information

NPI Number	:	1326017591
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOBILE HEALTH VAN

Provider Business Mailing Address
First Line	:	435 2ND ST
Second Line	:
City	:	NEWPORT
State	:	TN
Zip	:	37821-3703
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	435 2ND ST
Second Line	:
City	:	NEWPORT
State	:	TN
Zip	:	37821-3703
Country	:	US
Telephone Number	:	423-625-2200
Fax Number	:

Authorized Official
Title or Position	:	PRIVACY OFFICER
Name	:	BRENDA ELLIS
Credential	:	RHIT
Telephone Number	:	865-549-2121

Provider Enumeration Date	:	03/17/2006
Last Update Date	:	08/22/2020

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Directions to “MOBILE HEALTH VAN ” Practice Location

Language	Start Address	Practice Location

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