1164897161 NPI number — OZARKS RESOURCE GROUP

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1164897161 NPI number — OZARKS RESOURCE GROUP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
OZARKS RESOURCE GROUP
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:
OZARKS COMMUNITY HEALTH CENTER - MILES FOR SMILES
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:
1164897161
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/20/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 125
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HERMITAGE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65668-0125
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-745-2121
Provider Business Mailing Address Fax Number:
417-745-0056

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
203 E. BROADWAY ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLIVAR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65613
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-328-6334
Provider Business Practice Location Address Fax Number:
417-326-8111
Provider Enumeration Date:
12/02/2015

Additional Information

Authorized Official

Authorized Official Last Name:
CROUCH
Authorized Official First Name:
SCOTT
Authorized Official Middle Name:
D
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
417-745-2121

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1639421050 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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