1619285731 NPI number — ALDEN MEDICAL CLINIC, LLC

Table of content: (NPI 1619285731)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1619285731 NPI number — ALDEN MEDICAL CLINIC, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ALDEN MEDICAL CLINIC, 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:
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:
1619285731
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/23/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 W 10TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAMAR
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64759-1405
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-682-5123
Provider Business Mailing Address Fax Number:
417-682-3445

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 W 10TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAMAR
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64759-1405
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-682-5123
Provider Business Practice Location Address Fax Number:
417-682-3445
Provider Enumeration Date:
09/23/2010

Additional Information

Authorized Official

Authorized Official Last Name:
ALDEN
Authorized Official First Name:
JOHN
Authorized Official Middle Name:
E
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
417-682-5123

Provider Taxonomy Codes

  • Taxonomy code: 207Q00000X , with the licence number:  R1H97 , 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: 242428001 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com