1124577986 NPI number — MYCRACO LLC

Table of content: (NPI 1124577986)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124577986 NPI number — MYCRACO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MYCRACO LLC
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:
MYCRACO LLC
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:
1124577986
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/22/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1238 TYLER LN
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NIXA
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65714-8368
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-315-4962
Provider Business Mailing Address Fax Number:
888-884-4101

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2053 S WAVERLY AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65804-2414
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-315-4962
Provider Business Practice Location Address Fax Number:
888-884-4101
Provider Enumeration Date:
09/22/2016

Additional Information

Authorized Official

Authorized Official Last Name:
COENEN
Authorized Official First Name:
CRAIG
Authorized Official Middle Name:
PATRICK
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
417-315-4962

Provider Taxonomy Codes

  • Taxonomy code: 101Y00000X , with the licence number:  2010024663 , 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: 1821137159 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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