1245250091 NPI number — NEW MEDICO HEALTHCARE CORPORATION

Table of content: (NPI 1245250091)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245250091 NPI number — NEW MEDICO HEALTHCARE CORPORATION

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
NEW MEDICO HEALTHCARE CORPORATION
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:
1245250091
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/25/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 209
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
OSAGE BEACH
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65065-0209
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-777-1182
Provider Business Mailing Address Fax Number:
417-777-1183

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3361 S SPRINGFIELD AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BOLIVAR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65613-9132
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-777-1182
Provider Business Practice Location Address Fax Number:
417-777-1183
Provider Enumeration Date:
07/21/2006

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
LORENZO
Authorized Official First Name:
EDILBERTO
Authorized Official Middle Name:
B
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-777-1182

Provider Taxonomy Codes

  • Taxonomy code: 101YP2500X , with the licence number:  002181 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X , with the licence number: 20010000520 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X , with the licence number: 33294 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 2084P0800X , with the licence number: 04-15475 , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0805X , with the licence number: R4566 , registered in the state of AR ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0805X , with the licence number: 0000029442 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 128988002 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 493986483 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 498904515 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 505355909 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 127191001 , issued by the state of ( AR ) . This identifiers is of the category "MEDICAID".
  • Identifier: 208100107 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".