Basic Information
Provider Information
NPI: 1235280892
EntityType: 2
ReplacementNPI:  
OrganizationName: FRONTIER HEALTH
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: INDEPENDENCE UNLIMITED
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: PO BOX 9054
Address2:  
City: GRAY
State: TN
PostalCode: 376159054
CountryCode: US
TelephoneNumber: 4234673600
FaxNumber: 4234673644
Practice Location
Address1: 4907 BOONE TRAIL RD
Address2:  
City: DUFFIELD
State: VA
PostalCode: 24244
CountryCode: US
TelephoneNumber: 2764314473
FaxNumber: 2764314484
Other Information
ProviderEnumerationDate: 01/12/2007
LastUpdateDate: 10/04/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: KIDD
AuthorizedOfficialFirstName: TERESA
AuthorizedOfficialMiddleName: M
AuthorizedOfficialTitleorPosition: PRESIDENT AND CEO
AuthorizedOfficialTelephone: 4234673600
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MRS.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential: PHD
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
251C00000X315-02-006VAY AgenciesDay Training, Developmentally Disabled Services 

No ID Information.


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