=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902839293
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MEMORIAL HOSPITAL, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/09/2006
-----------------------------------------------------
Last Update Date | 01/13/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 149 HEALTH CARE LN
-----------------------------------------------------
City | JELLICO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37762-4433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-784-2452
-----------------------------------------------------
Fax | 423-784-1184
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 149 HEALTH CARE LN
-----------------------------------------------------
City | JELLICO
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 37762-4433
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 423-784-1206
-----------------------------------------------------
Fax | 423-784-1136
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF FINANCIAL OFFICER
-----------------------------------------------------
Name | PAUL MERKLIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 606-598-1035
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number | 00000000-16
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------