Healthcare Provider Details

I. General information

NPI: 1053496901
Provider Name (Legal Business Name): MOUNTAIN STATES HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/26/2006
Last Update Date: 03/29/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

101 MED TECH PKWY SUITE 100
JOHNSON CITY TN
37604-4007
US

IV. Provider business mailing address

311 PRINCETON RD STE 1
JOHNSON CITY TN
37601-2026
US

V. Phone/Fax

Practice location:
  • Phone: 423-431-4601
  • Fax: 423-431-5733
Mailing address:
  • Phone: 423-431-4601
  • Fax: 423-431-5733

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251F00000X
TaxonomyHome Infusion Agency
License Number0000000434
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State

VIII. Authorized Official

Name: MARY LYNN KRUTAK
Title or Position: EVP/CFO
Credential:
Phone: 423-302-3423