Basic Information
| Provider Information | |||||||||
| NPI: | 1699101618 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | FRONTIER HEALTH | ||||||||
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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: | 1167 SPRATLIN PARK DR | ||||||||
| Address2: | |||||||||
| City: | GRAY | ||||||||
| State: | TN | ||||||||
| PostalCode: | 376156205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4234673600 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2013 | ||||||||
| LastUpdateDate: | 10/04/2018 | ||||||||
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| AuthorizedOfficialLastName: | DENTON | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | D | ||||||||
| AuthorizedOfficialTitleorPosition: | UM COORDINATIOR | ||||||||
| AuthorizedOfficialTelephone: | 4234673721 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | BSOM | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320800000X | Y | Residential Treatment Facilities | Community Based Residential Treatment Facility, Mental Illness |
No ID Information.