Provider Demographics
NPI:1326017591
Name:MOBILE HEALTH VAN
Entity Type:Organization
Organization Name:MOBILE HEALTH VAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRIVACY OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:BRENDA
Authorized Official - Middle Name:
Authorized Official - Last Name:ELLIS
Authorized Official - Suffix:
Authorized Official - Credentials:RHIT
Authorized Official - Phone:865-549-2121
Mailing Address - Street 1:435 2ND ST
Mailing Address - Street 2:
Mailing Address - City:NEWPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37821-3703
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:435 2ND ST
Practice Address - Street 2:
Practice Address - City:NEWPORT
Practice Address - State:TN
Practice Address - Zip Code:37821-3703
Practice Address - Country:US
Practice Address - Phone:423-625-2200
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-03-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN=========OtherTAX ID