1245554815 NPI number — M D M DO LLC

Table of content: (NPI 1245554815)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245554815 NPI number — M D M DO LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
M D M DO LLC
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:
1245554815
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/13/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
101 MAIN ST STE 1
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CASSVILLE
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
65625-1651
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-846-2277
Provider Business Mailing Address Fax Number:
417-846-0176

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
825 E HIGHWAY 60
Provider Second Line Business Practice Location Address:
SUITE H
Provider Business Practice Location Address City Name:
MONETT
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
65708-9311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-635-1177
Provider Business Practice Location Address Fax Number:
417-635-1180
Provider Enumeration Date:
03/25/2010

Additional Information

Authorized Official

Authorized Official Last Name:
MATTHEWS
Authorized Official First Name:
MARK
Authorized Official Middle Name:
D
Authorized Official Title or Position:
OWNER/PHYSICIAN
Authorized Official Telephone Number:
417-635-1177

Provider Taxonomy Codes

  • Taxonomy code: 261QR1300X , with the licence number:  114771 , 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)





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