Provider Demographics
NPI:1134129075
Name:WELLMONT WEXFORD HOUSE
Entity Type:Organization
Organization Name:WELLMONT WEXFORD HOUSE
Other - Org Name:THE WEXFORD HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EVP/CFO
Authorized Official - Prefix:
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KRUTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3423
Mailing Address - Street 1:311 PRINCETON RD STE 1
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37601-2026
Mailing Address - Country:US
Mailing Address - Phone:423-288-3988
Mailing Address - Fax:423-288-3273
Practice Address - Street 1:2421 N JOHN B DENNIS HWY
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4773
Practice Address - Country:US
Practice Address - Phone:423-288-3988
Practice Address - Fax:423-288-3273
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WELLMONT HEALTH SYSTEM
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-21
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN265313M00000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN7440529Medicaid
TN445207Medicare Oscar/Certification