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General NPI Number Information
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NPI Number | 1609984954
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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 | 08/28/2006
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Last Update Date | 10/30/2015
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Provider Practice Location Address
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Address Line | 2511 WESLEY ST
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City | JOHNSON CITY
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State | TN
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Zip | 37601-1723
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Country | US
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Telephone | 423-952-1700
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Fax | 423-431-6525
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Provider Business Mailing Address
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Address Line | 311 PRINCETON RD
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City | JOHNSON CITY
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State | TN
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Zip | 37601-2026
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | SVP/CFO
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Name | MARY LYNN KRUTAK
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Credential |
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Telephone | 423-302-3374
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 273Y00000X
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Taxonomy Name | Rehabilitation Hospital Unit
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License Number | 0000000121
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License Number State | TN
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