MEDICARE: MOUNTAIN HOME VAMC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QV0200X	VA Clinic/Center

General Provider Information

NPI Number	:	1700824646
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOUNTAIN HOME VAMC

Provider Business Mailing Address
First Line	:	PO BOX 94516
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44101
Country	:	US
Telephone Number	:	615-355-3451
Fax Number	:

Provider Business Practice Location Address
First Line	:	401 SCENIC DR
Second Line	:
City	:	ROGERSVILLE
State	:	TN
Zip	:	37857-2452
Country	:	US
Telephone Number	:	615-355-3451
Fax Number	:

Authorized Official
Title or Position	:	NPI TEAM MEMBER
Name	:	ERIN POTTER
Credential	:
Telephone Number	:	202-382-2579

Provider Enumeration Date	:	06/03/2006
Last Update Date	:	09/07/2017

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