1972649986 NPI number — NORTHEAST MISSOURI HEALTH COUNCIL, INC.

Table of content: (NPI 1972649986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972649986 NPI number — NORTHEAST MISSOURI HEALTH COUNCIL, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
NORTHEAST MISSOURI DENTAL CLINIC
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972649986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1416 CROWN DR
Provider Second Line Business Mailing Address:
P O BOX 1027
Provider Business Mailing Address City Name:
KIRKSVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63501-2548
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
660-627-5757
Provider Business Mailing Address Fax Number:
660-627-5802

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 W JEFFERSON ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KIRKSVILLE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63501-3407
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
660-665-2741
Provider Business Practice Location Address Fax Number:
660-665-3109
Provider Enumeration Date:
01/29/2007

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
GRIMM
Authorized Official First Name:
ANDREW
Authorized Official Middle Name:
H.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
660-627-5757

Provider Taxonomy Codes

  • Taxonomy code: 1223D0001X , with the licence number:  2001012903 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1223D0001X , with the licence number: 2006007559 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 124Q00000X , with the licence number: 003847 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QF0400X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 507477404 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".