1861590861 NPI number — ADVOCATES FOR A HEALTHY COMMUNITY, INC.

Table of content: (NPI 1861590861)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861590861 NPI number — ADVOCATES FOR A HEALTHY COMMUNITY, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ADVOCATES FOR A HEALTHY COMMUNITY, 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:
JORDAN VALLEY COMMUNITY HEALTH 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:
1861590861
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
440 E TAMPA ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRINGFIELD
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65806-1131
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-851-1551
Provider Business Mailing Address Fax Number:
417-831-0155

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
618 N BENTON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRINGFIELD
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65806-1102
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-831-0150
Provider Business Practice Location Address Fax Number:
417-831-0155
Provider Enumeration Date:
09/21/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MILLER
Authorized Official First Name:
KENNETH
Authorized Official Middle Name:
B
Authorized Official Title or Position:
CEO
Authorized Official Telephone Number:
417-831-0150

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: 26D1013631 . This is a "CLIA" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 506226703 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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