1083705529 NPI number — FAMILY WALK IN CLINIC OF MOUNTAIN GROVE INC

Table of content: (NPI 1083705529)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083705529 NPI number — FAMILY WALK IN CLINIC OF MOUNTAIN GROVE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FAMILY WALK IN CLINIC OF MOUNTAIN GROVE 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:
FAMILY WALK-IN CLINIC OF MTN. GROVE, INC.
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:
1083705529
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/12/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
205 W 3RD ST STE 3
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MOUNTAIN GROVE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65711-1600
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-926-3743
Provider Business Mailing Address Fax Number:
417-926-7625

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
205 W 3RD ST STE 3
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MOUNTAIN GROVE
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65711-1600
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-926-3743
Provider Business Practice Location Address Fax Number:
417-926-7625
Provider Enumeration Date:
09/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DUGAN
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
H
Authorized Official Title or Position:
VICE-PRESIDENT
Authorized Official Telephone Number:
417-926-3743

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 263939 . This is a "RIVERBEND" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 596020800 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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