Provider Demographics
NPI:1386813616
Name:MOUNTAIN STATES HEALTH ALLIANCE
Entity type:Organization
Organization Name:MOUNTAIN STATES HEALTH ALLIANCE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JUANITA
Authorized Official - Middle Name:
Authorized Official - Last Name:HARWOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-392-6565
Mailing Address - Street 1:1021 W OAKLAND AVE STE 310
Mailing Address - Street 2:
Mailing Address - City:JOHNSON CITY
Mailing Address - State:TN
Mailing Address - Zip Code:37604-2192
Mailing Address - Country:US
Mailing Address - Phone:423-302-6567
Mailing Address - Fax:276-762-0612
Practice Address - Street 1:16431 WISE ST
Practice Address - Street 2:
Practice Address - City:ST PAUL
Practice Address - State:VA
Practice Address - Zip Code:24283
Practice Address - Country:US
Practice Address - Phone:276-762-2300
Practice Address - Fax:276-762-0612
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-20
Last Update Date:2024-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VI020157701OtherDEPARTMENT OF LABOR
VA1386813616Medicaid
VAC10529Medicare PIN