Healthcare Provider Details

I. General information

NPI: 1548580046
Provider Name (Legal Business Name): JELLICO COMMUNITY HOSPITAL, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/07/2010
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

188 HOSPITAL LANE
JELLICO TN
37762-4400
US

IV. Provider business mailing address

188 HOSPITAL LANE
JELLICO TN
37762-4400
US

V. Phone/Fax

Practice location:
  • Phone: 423-784-1272
  • Fax: 423-784-1136
Mailing address:
  • Phone: 423-784-1272
  • Fax: 423-784-1136

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: EVELYN GHULAM
Title or Position: CONTROLLER
Credential:
Phone: 423-784-1334