Provider Demographics
NPI:1407154800
Name:JELLICO COMMUNITY HOSPITAL, INC
Entity Type:Organization
Organization Name:JELLICO COMMUNITY HOSPITAL, INC
Other - Org Name:CARE PLUS CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CONTROLLER
Authorized Official - Prefix:
Authorized Official - First Name:EVELYN
Authorized Official - Middle Name:
Authorized Official - Last Name:GHULAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-784-1334
Mailing Address - Street 1:188 HOSPITAL LANE
Mailing Address - Street 2:
Mailing Address - City:JELLICO
Mailing Address - State:TN
Mailing Address - Zip Code:37762-4433
Mailing Address - Country:US
Mailing Address - Phone:423-784-7252
Mailing Address - Fax:423-784-1136
Practice Address - Street 1:998 SOUTH HIGHWAY 25W
Practice Address - Street 2:
Practice Address - City:WILLAIMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769
Practice Address - Country:US
Practice Address - Phone:606-549-1183
Practice Address - Fax:606-549-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-09
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
261QM1300X
KYPA071363AM0700X
KY3007739363L00000X
KY3004431363L00000X
KY3002560363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-SpecialtyGroup - Multi-Specialty
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3610200Medicare PIN