Provider Demographics
NPI:1619181484
Name:OCOEE REGIONAL HEALTH CORPORATION
Entity Type:Organization
Organization Name:OCOEE REGIONAL HEALTH CORPORATION
Other - Org Name:BENTON FAMILY HEALTH CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILLIAM
Authorized Official - Middle Name:R
Authorized Official - Last Name:MOATS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-338-8995
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:TN
Mailing Address - Zip Code:37307-0308
Mailing Address - Country:US
Mailing Address - Phone:423-338-2831
Mailing Address - Fax:423-338-2833
Practice Address - Street 1:6784 HIGHWAY 411
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:TN
Practice Address - Zip Code:37307-4818
Practice Address - Country:US
Practice Address - Phone:423-338-2831
Practice Address - Fax:423-338-2833
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-10
Last Update Date:2021-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN3379622Medicare PIN
TN441817Medicare Oscar/Certification