1376550137 NPI number — MS. THERESA LEE CLANTON

Table of content: MS. THERESA LEE CLANTON (NPI 1376550137)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376550137 NPI number — MS. THERESA LEE CLANTON

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CLANTON
Provider First Name:
THERESA
Provider Middle Name:
LEE
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CLANTON
Provider Other First Name:
THERESA
Provider Other Middle Name:
LEE
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1376550137
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
696 CARTER ROUTE M
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
VAN BUREN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63965-7014
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-323-2171
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
402 MAIN ST.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VAN BUREN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63965
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-323-4853
Provider Business Practice Location Address Fax Number:
573-323-4465
Provider Enumeration Date:
08/02/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 376K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 246RP1900X , with the licence number: 475-1 , 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)