Healthcare Provider Details

I. General information

NPI: 1386813616
Provider Name (Legal Business Name): MOUNTAIN STATES HEALTH ALLIANCE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/20/2008
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16431 WISE ST
ST PAUL VA
24283
US

IV. Provider business mailing address

1021 W OAKLAND AVE STE 310
JOHNSON CITY TN
37604-2192
US

V. Phone/Fax

Practice location:
  • Phone: 276-762-2300
  • Fax: 276-762-0612
Mailing address:
  • Phone: 423-302-6567
  • Fax: 276-762-0612

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JUANITA HARWOOD
Title or Position: DIRECTOR
Credential:
Phone: 423-392-6565