1093020380 NPI number — FOUR OAKS INC

Table of content: (NPI 1093020380)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093020380 NPI number — FOUR OAKS INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
FOUR OAKS 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:
FOUR OAKS HOSPICE
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:
1093020380
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
731 N MAIN ST
Provider Second Line Business Mailing Address:
P.O. BOX 1210
Provider Business Mailing Address City Name:
SIKESTON
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63801-2151
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-471-1276
Provider Business Mailing Address Fax Number:
573-472-8504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1615 W BUSINESS US HIGHWAY 60
Provider Second Line Business Practice Location Address:
SUITE A & B
Provider Business Practice Location Address City Name:
DEXTER
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63841-2838
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-624-3655
Provider Business Practice Location Address Fax Number:
573-624-4323
Provider Enumeration Date:
08/11/2010

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BEDELL
Authorized Official First Name:
DONALD
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
573-471-1276

Provider Taxonomy Codes

  • Taxonomy code: 251G00000X , with the licence number:  192-4HO , 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)