Healthcare Provider Details

I. General information

NPI: 1538181409
Provider Name (Legal Business Name): DANCING HORIZON HEALTH FOUNDATION, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/23/2006
Last Update Date: 07/18/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2400 BOONSLICK DRIVE
BOONVILLE MO
65233
US

IV. Provider business mailing address

PO BOX 5111
SPRINGFIELD MO
65802
US

V. Phone/Fax

Practice location:
  • Phone: 660-882-9840
  • Fax: 660-882-3504
Mailing address:
  • Phone: 417-429-2180
  • Fax: 417-832-9799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberRIF83
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number StateMO

VIII. Authorized Official

Name: KEVIN W LOUDERBACK
Title or Position: MANAGING PARTNER
Credential: HHP CHT PSYD
Phone: 417-429-2180