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Organization
MOUNTAIN STATES HEALTH ALLIANCE
Active
Organization
MOUNTAIN STATES HEALTH ALLIANCE
Active
Other names
Indian Path Pavilion
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. MARY L KRUTAK (SVP/CFO)
(423) 431-6111
Entity
Organization
Contact information
Practice address
2300 PAVILION DR, KINGSPORT, TN 37660-4622
(423) 857-5500
(423) 857-7078
Mailing address
311 PRINCETON RD, JOHNSON CITY, TN 37601-2026
(423) 431-1941
(423) 431-1244
Taxonomy
Speciality
Code
Description
License number
State
273R00000X
Psychiatric Hospital Unit
Primary
0000000134
TN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
000127730
—
SC
05
—
000363855X
—
GA
05
—
004401760
—
VA
05
—
00672239
—
MS
05
—
01600113
—
KY
05
—
091618800
—
FL
05
—
0938025
—
OH
01
—
17505000
MEGELLAN
—
05
—
4400176
—
NC
05
—
4699873
—
MI
Enumeration date
09/07/2006
Last updated
10/15/2015
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