Provider Demographics
NPI:1639183353
Name:CAMPBELL COUNTY HMA LLC
Entity Type:Organization
Organization Name:CAMPBELL COUNTY HMA LLC
Other - Org Name:TENNOVA LAFOLLETTE MEDICAL CENTER CLINIC-JACKSBORO
Other - Org Type:Other Name
Authorized Official - Title/Position:DIRECTOR/DELEGATED OFFICIAL
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:M
Authorized Official - Last Name:LALOR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:629-215-3953
Mailing Address - Street 1:PO BOX 743615
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3615
Mailing Address - Country:US
Mailing Address - Phone:423-907-1700
Mailing Address - Fax:423-907-1711
Practice Address - Street 1:2145 JACKSBORO PIKE
Practice Address - Street 2:
Practice Address - City:LA FOLLETTE
Practice Address - State:TN
Practice Address - Zip Code:37766-3003
Practice Address - Country:US
Practice Address - Phone:423-907-1700
Practice Address - Fax:423-907-1711
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-28
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN443440Medicare Oscar/Certification