MEDICARE: WELLMONT HEALTH SYSTEM, INC

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	251E00000X	Home Health Agency	0000000249	TN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	0000000249	OTHER	TN	STATE LICENSE

General Provider Information

NPI Number	:	1972584092
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	WELLMONT HEALTH SYSTEM, INC

Provider Business Mailing Address
First Line	:	2971 FORT HENRY DR
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-4005
Country	:	US
Telephone Number	:	423-230-8450
Fax Number	:	423-245-7874

Provider Business Practice Location Address
First Line	:	2971 FORT HENRY DR
Second Line	:
City	:	KINGSPORT
State	:	TN
Zip	:	37664-4005
Country	:	US
Telephone Number	:	423-230-8450
Fax Number	:	423-245-7874

Authorized Official
Title or Position	:	INTERIM DIRECTOR
Name	:	MRS. CAROL J KAWCHAK
Credential	:
Telephone Number	:	423-230-8475

Provider Enumeration Date	:	11/07/2005
Last Update Date	:	08/22/2020

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Directions to “WELLMONT HEALTH SYSTEM, INC ” Practice Location

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