1588858997 NPI number — SOUTHWEST MO FOOT CLINICS

Table of content: (NPI 1588858997)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1588858997 NPI number — SOUTHWEST MO FOOT CLINICS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SOUTHWEST MO FOOT CLINICS
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:
1588858997
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 3592
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64803-3592
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-782-7500
Provider Business Mailing Address Fax Number:
417-782-7524

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2024 S MAIDEN LN STE 201
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-0319
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-782-7500
Provider Business Practice Location Address Fax Number:
417-782-7524
Provider Enumeration Date:
08/29/2007

Additional Information

Authorized Official

Authorized Official Last Name:
RICHINS
Authorized Official First Name:
MATTHEW
Authorized Official Middle Name:
B
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
417-782-7500

Provider Taxonomy Codes

  • Taxonomy code: 332BC3200X , with the licence number:  2006009605 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 335E00000X , with the licence number: 2006009605 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 332B00000X , with the licence number: 2006009605 , 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: 626280200 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: P00408461 . This is a "RAILROAD MEDICARE PROVIDE" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: DG0016 . This is a "RAILROAD MEDICARE GROUP" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 212522 . This is a "BCBS MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 000015173 . This is a "MEDICARE GROUP MO" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 114142 . This is a "KANSAS MEDICARE PROVIDER" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 114206 . This is a "KANSAS MEDICARE GROUP" identifier , issued by the state of ( KS ) . This identifiers is of the category "OTHER".
  • Identifier: 301595708 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 20422090B , issued by the state of ( KS ) . This identifiers is of the category "MEDICAID".
  • Identifier: 504920901 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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