Healthcare Provider Details

I. General information

NPI: 1194886788
Provider Name (Legal Business Name): FRONTIER HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 10/04/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 US HIGHWAY 58
DUFFIELD VA
24244
US

IV. Provider business mailing address

PO BOX 9054
GRAY TN
37615-9054
US

V. Phone/Fax

Practice location:
  • Phone: 276-431-4370
  • Fax: 276-431-2863
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number315-16-001
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number315-07-004
License Number StateVA
# 3
Primary TaxonomyN
Taxonomy Code385HR2055X
TaxonomyChild Mental Illness Respite Care
License Number315-03-001
License Number StateVA
# 4
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number315-03-001
License Number StateVA

VIII. Authorized Official

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