1316344658 NPI number — ICARE PRIMARY CARE

Table of content: (NPI 1316344658)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316344658 NPI number — ICARE PRIMARY CARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ICARE PRIMARY CARE
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:
ICARE ADDICTION CLINIC
Provider Other Organization Name Type Code:
5
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:
1316344658
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/02/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
550 RUSH CREEK PKWY
Provider Second Line Business Mailing Address:
SUITE B
Provider Business Mailing Address City Name:
LIBERTY
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64068-9608
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
816-875-4325
Provider Business Mailing Address Fax Number:
816-407-9809

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
550 RUSH CREEK PKWY
Provider Second Line Business Practice Location Address:
SUITE B
Provider Business Practice Location Address City Name:
LIBERTY
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64068-9608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-875-4325
Provider Business Practice Location Address Fax Number:
816-407-9809
Provider Enumeration Date:
12/02/2014

Additional Information

Authorized Official

Authorized Official Last Name:
PETERSEN
Authorized Official First Name:
JENNIFER
Authorized Official Middle Name:
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
816-875-4325

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  20110330076 , 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: 1699716910 . This is a "PHYSICIAN" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com