Provider Demographics
NPI:1326141896
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity Type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:INDIAN PATH MEDICAL CENTER TRANSITIONAL CARE UNIT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP/CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:MARY
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:KRUTAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-302-3774
Mailing Address - Street 1:311 PRINCETON RD
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:
Mailing Address - Fax:
Practice Address - Street 1:2000 BROOKSIDE DR
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4627
Practice Address - Country:US
Practice Address - Phone:423-857-7000
Practice Address - Fax:423-857-7078
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-07
Last Update Date:2015-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000336314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC4400176Medicaid
KY01600113Medicaid
MI4699873Medicaid
GA000363855XMedicaid
OH0938025Medicaid
FL091618800Medicaid
SC000127730Medicaid
MS00672239Medicaid
VA004401760Medicaid
SC000127730Medicaid