Provider Demographics
NPI:1891952248
Name:JELLICO COMMUNITY HOSPITAL, INC
Entity Type:Organization
Organization Name:JELLICO COMMUNITY HOSPITAL, INC
Other - Org Name:CARE PLUS REHAB
Other - Org Type:Doing Business As
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 LN
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:723-784-1136
Practice Address - Street 1:998 S HIGHWAY 25 W
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:KY
Practice Address - Zip Code:40769-1692
Practice Address - Country:US
Practice Address - Phone:606-549-1183
Practice Address - Fax:606-549-8107
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-21
Last Update Date:2016-03-10
Deactivation Date:2011-12-06
Deactivation Code:
Reactivation Date:2012-05-22
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes273Y00000XHospital UnitsRehabilitation Unit
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY01620848Medicaid
TN0440180Medicaid
440180Medicare PIN