Provider Demographics
NPI:1023022084
Name:DAYSPRING HEALTH INC
Entity Type:Organization
Organization Name:DAYSPRING HEALTH INC
Other - Org Name:DAYSPRING JELLICO
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:GEOGY
Authorized Official - Middle Name:
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:423-784-8492
Mailing Address - Street 1:107 S MAIN ST
Mailing Address - Street 2:P.O. BOX 540
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-2154
Mailing Address - Country:US
Mailing Address - Phone:423-784-8492
Mailing Address - Fax:423-784-8358
Practice Address - Street 1:550 SUNSET TRL
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762
Practice Address - Country:US
Practice Address - Phone:423-784-5771
Practice Address - Fax:423-784-6185
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-27
Last Update Date:2022-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
207Q00000X, 363A00000X, 363L00000X
TN43450207V00000X
TN441853261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)Group - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN204123OtherBLACK LUNG
TN4447931Medicaid
KY65903650Medicaid
TN0980730OtherUMWA
TN0980730OtherUMWA
TN204123OtherBLACK LUNG