1134295108 NPI number — STATE OF MISSOURI

Table of content: (NPI 1134295108)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1134295108 NPI number — STATE OF MISSOURI

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
STATE OF MISSOURI
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:
6
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:
1134295108
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/27/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1706 E ELM ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JEFFERSON CITY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65101-4130
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
573-751-3398
Provider Business Mailing Address Fax Number:
573-526-4560

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2351 KANELL BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POPLAR BLUFF
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63901-4035
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
573-840-9300
Provider Business Practice Location Address Fax Number:
573-840-9311
Provider Enumeration Date:
11/28/2006

Additional Information

Authorized Official

Authorized Official Last Name:
BOECKMANN
Authorized Official First Name:
MOLLY
Authorized Official Middle Name:
JANE
Authorized Official Title or Position:
DIRECTOR OF ADMINISTRATIVE SERVICES
Authorized Official Telephone Number:
573-751-4055

Provider Taxonomy Codes

  • Taxonomy code: 251C00000X , with the licence number:  EXEMPT , 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: 851793117 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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