MEDICARE: SALT RIVER COMMUNITY HEALTH CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)	19782870	MO
2	261QC1500X	Community Health Clinic/Center	19782870	MO

General Provider Information

NPI Number	:	1750422457
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	SALT RIVER COMMUNITY HEALTH CENTER

Provider Business Mailing Address
First Line	:	3145 HIGHWAY 61
Second Line	:
City	:	HANNIBAL
State	:	MO
Zip	:	63401-6588
Country	:	US
Telephone Number	:	573-221-4422
Fax Number	:	573-221-4470

Provider Business Practice Location Address
First Line	:	3145 HIGHWAY 61
Second Line	:
City	:	HANNIBAL
State	:	MO
Zip	:	63401-6588
Country	:	US
Telephone Number	:	573-221-1166
Fax Number	:	573-221-1214

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	JOAN F HYNEK
Credential	:
Telephone Number	:	573-221-4422

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	07/21/2010

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Directions to “SALT RIVER COMMUNITY HEALTH CENTER ” Practice Location

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