Basic Information
| Provider Information | |||||||||
| NPI: | 1841887064 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FRONTIER HEALTH | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | LEE HIGH SCHOOL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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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: | 200 GENERAL LN | ||||||||
| Address2: | |||||||||
| City: | JONESVILLE | ||||||||
| State: | VA | ||||||||
| PostalCode: | 242638103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2763460173 | ||||||||
| FaxNumber: | 4234673644 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2020 | ||||||||
| LastUpdateDate: | 03/10/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DENTON | ||||||||
| AuthorizedOfficialFirstName: | ROBIN | ||||||||
| AuthorizedOfficialMiddleName: | DENISE | ||||||||
| AuthorizedOfficialTitleorPosition: | UM COORDINATOR | ||||||||
| AuthorizedOfficialTelephone: | 4234673600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 03/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No ID Information.