Provider Demographics
NPI:1104928514
Name:WYTHE COUNTY COMMUNITY HOSPITAL LLC
Entity type:Organization
Organization Name:WYTHE COUNTY COMMUNITY HOSPITAL LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VICTOR
Authorized Official - Middle Name:E
Authorized Official - Last Name:GIOVANETTI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:615-920-7000
Mailing Address - Street 1:330 SEVEN SPRINGS WAY
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5098
Mailing Address - Country:US
Mailing Address - Phone:615-920-7000
Mailing Address - Fax:615-920-8913
Practice Address - Street 1:600 W RIDGE RD
Practice Address - Street 2:HOSPICE OF SOUTHWEST VIRGINIA
Practice Address - City:WYTHEVILLE
Practice Address - State:VA
Practice Address - Zip Code:24382
Practice Address - Country:US
Practice Address - Phone:276-228-1710
Practice Address - Fax:276-228-1719
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-05
Last Update Date:2017-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VAHSP06121251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA004910141Medicaid
VA004910141Medicaid
VA491521Medicare Oscar/Certification