1174522882 NPI number — ELK RIVER HEALTH SERVICES, INC.

Table of content: (NPI 1174522882)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174522882 NPI number — ELK RIVER HEALTH SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELK RIVER HEALTH SERVICES, 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:
SOUTHWEST CITY COMMUNITY 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:
1174522882
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
04/15/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 160
Provider Second Line Business Mailing Address:
109 N BROADWAY
Provider Business Mailing Address City Name:
SOUTH WEST CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64863-0160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-762-3287
Provider Business Mailing Address Fax Number:
417-762-3255

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
109 N BROADWAY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH WEST CITY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64863-9417
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-762-3287
Provider Business Practice Location Address Fax Number:
417-762-3255
Provider Enumeration Date:
07/15/2005

Additional Information

Authorized Official

Authorized Official Last Name:
PLUMLEE
Authorized Official First Name:
VICKI
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF CLINICS
Authorized Official Telephone Number:
417-762-3287

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261QR1300X , registered in the state of OK ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 596813808 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 506813815 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 100713200A , issued by the state of ( OK ) . This identifiers is of the category "MEDICAID".




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