=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376933580
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DICKENSON COMMUNITY HOSPITAL, INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/26/2015
-----------------------------------------------------
Last Update Date | 04/24/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 312 HOSPITAL DR
-----------------------------------------------------
City | CLINTWOOD
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 24228-6786
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-926-0251
-----------------------------------------------------
Fax | 276-926-0329
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 311 PRINCETON RD STE 1
-----------------------------------------------------
City | JOHNSON CITY
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37601-2026
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 276-926-0251
-----------------------------------------------------
Fax | 276-926-0329
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EVP/CFO
-----------------------------------------------------
Name | SHANE EDWIN HILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 423-302-3467
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 273R00000X
-----------------------------------------------------
Taxonomy Name | Psychiatric Hospital Unit
-----------------------------------------------------
License Number | 0000000119
-----------------------------------------------------
License Number State | VA
-----------------------------------------------------