Healthcare Provider Details

I. General information

NPI: 1609984954
Provider Name (Legal Business Name): MOUNTAIN STATES HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 10/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 WESLEY ST
JOHNSON CITY TN
37601-1723
US

IV. Provider business mailing address

311 PRINCETON RD
JOHNSON CITY TN
37601-2026
US

V. Phone/Fax

Practice location:
  • Phone: 423-952-1700
  • Fax: 423-431-6525
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code273Y00000X
TaxonomyRehabilitation Hospital Unit
License Number0000000121
License Number StateTN

VIII. Authorized Official

Name: MARY LYNN KRUTAK
Title or Position: SVP/CFO
Credential:
Phone: 423-302-3374