Healthcare Provider Details

I. General information

NPI: 1346308749
Provider Name (Legal Business Name): DANCING HORIZON HEALTH LC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2006
Last Update Date: 10/22/2007
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
65801
US

V. Phone/Fax

Practice location:
  • Phone: 660-882-9840
  • Fax: 660-882-3504
Mailing address:
  • Phone: 417-429-2185
  • Fax: 417-832-9799

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License NumberR1F83
License Number StateMO

VIII. Authorized Official

Name: KEVIN W LOUDERBACK
Title or Position: MANAGER
Credential: HHP
Phone: 417-429-2181