Provider Demographics
NPI:1750720058
Name:CAMELLIA HOME HEALTH OF SOUTHEAST TENNESSEE, LLC
Entity type:Organization
Organization Name:CAMELLIA HOME HEALTH OF SOUTHEAST TENNESSEE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT / CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:WILFORD
Authorized Official - Middle Name:A
Authorized Official - Last Name:PAYNE
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:601-544-2903
Mailing Address - Street 1:135 MAYFAIR RD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-1464
Mailing Address - Country:US
Mailing Address - Phone:601-544-2903
Mailing Address - Fax:601-579-6991
Practice Address - Street 1:6711 MOUNTAIN VIEW RD
Practice Address - Street 2:SUITE 105
Practice Address - City:OOLTEWAH
Practice Address - State:TN
Practice Address - Zip Code:37363-6668
Practice Address - Country:US
Practice Address - Phone:423-414-3017
Practice Address - Fax:423-238-1199
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-06-19
Last Update Date:2013-06-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN107251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
447198Medicare Oscar/Certification