Provider Demographics
NPI:1902887680
Name:WELLMONT HEALTH SYSTEM, INC
Entity Type:Organization
Organization Name:WELLMONT HEALTH SYSTEM, INC
Other - Org Name:WELLMONT BRISTOL REGIONAL MEDICAL CENTER HOME HEALTH
Other - Org Type:Other Name
Authorized Official - Title/Position:INTERIM DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:CAROL
Authorized Official - Middle Name:J
Authorized Official - Last Name:KAWCHAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-230-8475
Mailing Address - Street 1:240 MEDICAL PARK BLVD
Mailing Address - Street 2:SUITE 2600
Mailing Address - City:BRISTOL
Mailing Address - State:TN
Mailing Address - Zip Code:37620-7346
Mailing Address - Country:US
Mailing Address - Phone:423-844-5530
Mailing Address - Fax:
Practice Address - Street 1:240 MEDICAL PARK BLVD
Practice Address - Street 2:SUITE 2600
Practice Address - City:BRISTOL
Practice Address - State:TN
Practice Address - Zip Code:37620-7346
Practice Address - Country:US
Practice Address - Phone:423-844-5530
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-09
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN0000000248251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN447497Medicare ID - Type Unspecified