Basic Information
| Provider Information | |||||||||
| NPI: | 1174982193 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | WISE COUNTY INTEGRATED CARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1167 SPRATLIN PARK DR | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376156205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234673600 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Practice Location | |||||||||
| Address1: | 43 CHAMPIONS AVE | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BIG STONE GAP | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242191105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2765238300 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/18/2016 | ||||||||
| LastUpdateDate: | 02/18/2016 | ||||||||
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| AuthorizedOfficialLastName: | KIDD | ||||||||
| AuthorizedOfficialFirstName: | TERESA | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT & CEO | ||||||||
| AuthorizedOfficialTelephone: | 4234673600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | FRONTIER HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | DR. | ||||||||
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| AuthorizedOfficialCredential: | PHD | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QP2300X | 315-07-004 | VA | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
No ID Information.