Healthcare Provider Details

I. General information

NPI: 1427566694
Provider Name (Legal Business Name): BROADWAY FAMILY CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/22/2018
Last Update Date: 08/08/2023
Certification Date: 08/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 STATE HIGHWAY 25 S
BLOOMFIELD MO
63825-9566
US

IV. Provider business mailing address

612 HWY 25 SOUTH
BLOOMFIELD MO
63825-9566
US

V. Phone/Fax

Practice location:
  • Phone: 573-803-3995
  • Fax: 573-803-5222
Mailing address:
  • Phone: 573-568-7377
  • Fax: 573-568-7320

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2014044250
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number126560
License Number StateMO

VIII. Authorized Official

Name: MELISSA JARRELL
Title or Position: OFFICE/BILLING SUPERVISOR
Credential:
Phone: 573-568-7377