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General NPI Number Information
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NPI Number | 1104158054
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Entity Type | Organization
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Legal Business Name | MOUNTAIN STATES HEALTH ALLIANCE
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Dates
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Enumeration Date | 02/03/2010
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Last Update Date | 02/03/2010
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Provider Practice Location Address
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Address Line | 58 CARROLL ST
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City | LEBANON
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State | VA
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Zip | 24266-3600
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Country | US
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Telephone | 276-883-8101
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 3600
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City | LEBANON
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State | VA
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Zip | 24266-0200
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Country | US
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Telephone | 276-883-8101
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Fax |
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Authorized Official
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Title or Position | AVP/ADMINISTRATOR
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Name | EDDIE C GREENE
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Credential |
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Telephone | 246-883-8101
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2085R0202X
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Taxonomy Name | Diagnostic Radiology Physician
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License Number |
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License Number State |
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