Provider Demographics
NPI:1972782175
Name:WELLMONT HEALTH SYSTEM
Entity Type:Organization
Organization Name:WELLMONT HEALTH SYSTEM
Other - Org Name:JENKINS FAMILY CARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO/EXEC. V.P.
Authorized Official - Prefix:MR
Authorized Official - First Name:CHRISTOPHER
Authorized Official - Middle Name:D
Authorized Official - Last Name:KNIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-230-8200
Mailing Address - Street 1:1 MEDICAL PARK BLVD
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7430
Mailing Address - Country:US
Mailing Address - Phone:423-844-4711
Mailing Address - Fax:
Practice Address - Street 1:9480 HIGHWAY 805
Practice Address - Street 2:
Practice Address - City:JENKINS
Practice Address - State:KY
Practice Address - Zip Code:41537-8182
Practice Address - Country:US
Practice Address - Phone:606-832-2171
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-24
Last Update Date:2008-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY31000888Medicaid
KY3979Medicare PIN