Healthcare Provider Details

I. General information

NPI: 1104916337
Provider Name (Legal Business Name): OGMC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 S BROADWAY
OAK GROVE MN
64075
US

IV. Provider business mailing address

PO BOX 670 1900 S BROADWAY
OAK GROVE MO
64075
US

V. Phone/Fax

Practice location:
  • Phone: 816-690-6566
  • Fax: 816-625-8276
Mailing address:
  • Phone: 816-690-6566
  • Fax: 816-625-8276

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: STEVE T GIALDE
Title or Position: PARTNER
Credential: DO
Phone: 816-690-6566