Basic Information
Provider Information | |||||||||
NPI: | 1972654010 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FRONTIER HEALTH | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | HILLCREST GROUP HOME | ||||||||
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: | 137 FRALEY AVE | ||||||||
Address2: |   | ||||||||
City: | DUFFIELD | ||||||||
State: | VA | ||||||||
PostalCode: | 242449797 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2764314760 | ||||||||
FaxNumber: | 2764314506 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/16/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | VARNEY | ||||||||
AuthorizedOfficialFirstName: | E | ||||||||
AuthorizedOfficialMiddleName: | DOUGLAS | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT AND CEO | ||||||||
AuthorizedOfficialTelephone: | 4234673600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320900000X | 315-01-001 | VA | X |   | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |   | 385HR2060X | 315-01-001 | VA | X |   | Respite Care Facility | Respite Care | Respite Care, Mental Retardation and/or Developmental Disabilities, Child |
No ID Information.