1285896993 NPI number — MONTGOMERY COUNTY COMMUNITY CLINIC, INC

Table of content: (NPI 1285896993)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1285896993 NPI number — MONTGOMERY COUNTY COMMUNITY CLINIC, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MONTGOMERY COUNTY COMMUNITY CLINIC, 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:
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:
1285896993
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/25/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 612
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
INDEPENDENCE
Provider Business Mailing Address State Name:
KS
Provider Business Mailing Address Postal Code:
67301-0612
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
620-331-8190
Provider Business Mailing Address Fax Number:
620-652-4143

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
900 W MYRTLE ST
Provider Second Line Business Practice Location Address:
SUITE 105
Provider Business Practice Location Address City Name:
INDEPENDENCE
Provider Business Practice Location Address State Name:
KS
Provider Business Practice Location Address Postal Code:
67301-3242
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
620-331-8190
Provider Business Practice Location Address Fax Number:
620-652-4143
Provider Enumeration Date:
06/25/2008

Additional Information

Authorized Official

Authorized Official Last Name:
KLEINBECK
Authorized Official First Name:
SUSAN
Authorized Official Middle Name:
V.M.
Authorized Official Title or Position:
EXECUTIVE DIRECTOR
Authorized Official Telephone Number:
620-331-8190

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X , with the licence number:  NONE REQUIRED , registered in the state of KS ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com