Provider Demographics
NPI:1801018387
Name:FRONTIER HEALTH
Entity Type:Organization
Organization Name:FRONTIER HEALTH
Other - Org Name:R. GRANT WIDNER GROUP HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MS
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 1:4121 OLD JONESBORO RD
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-5342
Practice Address - Country:US
Practice Address - Phone:423-652-7378
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:FRONTIER HEALTH
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-05-03
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN20647320800000X
TNL 324-076-1424320900000X
TNL324-076-1424323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility