Healthcare Provider Details

I. General information

NPI: 1134282551
Provider Name (Legal Business Name): FRONTIER HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2006
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

607 BAXTER ST
JOHNSON CITY TN
37601-4003
US

IV. Provider business mailing address

PO BOX 9054
GRAY TN
37615-9054
US

V. Phone/Fax

Practice location:
  • Phone: 423-232-2670
  • Fax: 423-928-0381
Mailing address:
  • Phone: 423-467-3600
  • Fax: 423-467-3644

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License NumberL-214-076-1412
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License NumberL-214-076-1412
License Number StateTN
# 3
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number319
License Number StateTN

VIII. Authorized Official

Name: MRS. TERESA M KIDD
Title or Position: PRESIDENT AND CEO
Credential: PHD
Phone: 423-467-3600