Provider Demographics
NPI:1508917642
Name:FRONTIER HEALTH
Entity Type:Organization
Organization Name:FRONTIER HEALTH
Other - Org Name:SUPPORTED LIVING - KINGSPORT
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:423-467-3600
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:423-467-3600
Mailing Address - Fax:423-467-3644
Practice Address - Street 1:2017 STONEBROOK PL
Practice Address - Street 2:
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-4000
Practice Address - Country:US
Practice Address - Phone:423-224-1417
Practice Address - Fax:423-224-1418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNL 3(20)24M3-076-1414251S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health