Healthcare Provider Details

I. General information

NPI: 1689749749
Provider Name (Legal Business Name): ST. MARY'S MEDICAL CENTER OF CAMPBELL COUNTY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/22/2006
Last Update Date: 09/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 TORREY RD
LA FOLLETTE TN
37766-2728
US

IV. Provider business mailing address

923 E CENTRAL AVE
LA FOLLETTE TN
37766-2768
US

V. Phone/Fax

Practice location:
  • Phone: 423-907-1379
  • Fax: 423-907-1189
Mailing address:
  • Phone: 423-907-1200
  • Fax: 423-907-1164

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. ANGEL DAVID JIMENEZ
Title or Position: PRESIDENT & CEO
Credential:
Phone: 865-545-7558