Provider Demographics
NPI:1194886788
Name:FRONTIER HEALTH
Entity type:Organization
Organization Name:FRONTIER HEALTH
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT AND CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:TERESA
Authorized Official - Middle Name:M
Authorized Official - Last Name:KIDD
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:423-467-3600
Mailing Address - Street 1:PO BOX 9054
Mailing Address - Street 2:
Mailing Address - City:GRAY
Mailing Address - State:TN
Mailing Address - Zip Code:37615-9054
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1100 US HIGHWAY 58
Practice Address - Street 2:
Practice Address - City:DUFFIELD
Practice Address - State:VA
Practice Address - Zip Code:24244
Practice Address - Country:US
Practice Address - Phone:276-431-4370
Practice Address - Fax:276-431-2863
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-13
Last Update Date:2018-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA315-16-001251B00000X
VA315-07-004261QM0855X
VA315-03-001385HR2055X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
No251B00000XAgenciesCase Management
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No385HR2055XRespite Care FacilityRespite CareRespite Care, Mental Illness, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA49-4129-2Medicaid