Healthcare Provider Details

I. General information

NPI: 1881797371
Provider Name (Legal Business Name): MOUNTAIN STATES HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/07/2006
Last Update Date: 04/16/2024
Certification Date: 04/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

403 N STATE OF FRANKLIN RD
JOHNSON CITY TN
37604-6034
US

IV. Provider business mailing address

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

V. Phone/Fax

Practice location:
  • Phone: 423-431-7111
  • Fax: 423-431-7301
Mailing address:
  • Phone: 423-431-7111
  • Fax: 423-431-7301

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273R00000X
TaxonomyPsychiatric Hospital Unit
License Number000000121
License Number StateTN

VIII. Authorized Official

Name: SHANE EDWIN HILTON
Title or Position: EVP/CFO
Credential:
Phone: 423-302-3467