1477646552 NPI number — CHRISTIAN HEALTH CARE OF LEBANON NORTH, INC.

Table of content: (NPI 1477646552)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477646552 NPI number — CHRISTIAN HEALTH CARE OF LEBANON NORTH, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHRISTIAN HEALTH CARE OF LEBANON NORTH, 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:
Provider Other Organization Name Type Code:
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:
1477646552
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/20/2011
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
222 S 1ST ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ROGERS
Provider Business Mailing Address State Name:
AR
Provider Business Mailing Address Postal Code:
72756-4504
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
479-464-0200
Provider Business Mailing Address Fax Number:
479-464-8098

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
596 MORTON RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LEBANON
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65536-3648
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-532-9173
Provider Business Practice Location Address Fax Number:
417-532-8223
Provider Enumeration Date:
10/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
STAYTON
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
417-891-9939

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  032279 , 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: 101489409 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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