1205883980 NPI number — KENNETT HMA LLC

Table of content: (NPI 1205883980)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1205883980 NPI number — KENNETT HMA LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KENNETT HMA 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:
TWIN RIVERS REGIONAL MEDICAL CENTER
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:
1205883980
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 281375
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ATLANTA
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
30384-1375
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-888-8421
Provider Business Mailing Address Fax Number:
573-888-5525

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1301 1ST ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KENNETT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63857-2525
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-888-8421
Provider Business Practice Location Address Fax Number:
573-888-5525
Provider Enumeration Date:
05/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
LALOR
Authorized Official First Name:
PAULA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
DIRECTOR/DELEGATED OFFICIAL
Authorized Official Telephone Number:
615-925-4565

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 208000000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR1300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 282N00000X , with the licence number: 4861 , 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: 010492809 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 184 . This is a "BLUE CROSS" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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