Healthcare Provider Details

I. General information

NPI: 1144993171
Provider Name (Legal Business Name): OCOEE REGIONAL HEALTH CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2021
Last Update Date: 07/27/2021
Certification Date: 06/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 DOUBLE S RD
DAYTON TN
37321-5344
US

IV. Provider business mailing address

PO BOX 308
BENTON TN
37307-0308
US

V. Phone/Fax

Practice location:
  • Phone: 423-338-8995
  • Fax: 423-338-8996
Mailing address:
  • Phone: 423-338-8995
  • Fax: 423-338-8996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM MOATS
Title or Position: PRESIDENT/CEO
Credential:
Phone: 423-338-8995