Provider Demographics
NPI:1902010770
Name:OCOEE REGIONAL HEALTH CORPORATION
Entity Type:Organization
Organization Name:OCOEE REGIONAL HEALTH CORPORATION
Other - Org Name:GRUNDY COUNTY PRIMARY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BILL
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 70
Mailing Address - Street 2:
Mailing Address - City:PALMER
Mailing Address - State:TN
Mailing Address - Zip Code:37365-0070
Mailing Address - Country:US
Mailing Address - Phone:931-779-4002
Mailing Address - Fax:931-779-4003
Practice Address - Street 1:10120 SR 56
Practice Address - Street 2:
Practice Address - City:COALMONT
Practice Address - State:TN
Practice Address - Zip Code:37313-2505
Practice Address - Country:US
Practice Address - Phone:931-779-4002
Practice Address - Fax:931-779-4003
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
TN441867Medicare Oscar/Certification
TN3379622Medicare PIN