Provider Demographics
NPI:1548580046
Name:JELLICO COMMUNITY HOSPITAL, INC
Entity Type:Organization
Organization Name:JELLICO COMMUNITY HOSPITAL, INC
Other - Org Name:
Other - Org Type:
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:37762-4400
Mailing Address - Country:US
Mailing Address - Phone:423-784-1272
Mailing Address - Fax:423-784-1136
Practice Address - Street 1:188 HOSPITAL LANE
Practice Address - Street 2:
Practice Address - City:JELLICO
Practice Address - State:TN
Practice Address - Zip Code:37762-4400
Practice Address - Country:US
Practice Address - Phone:423-784-1272
Practice Address - Fax:423-784-1136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-07
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN0056883OtherBLUECARE