Healthcare Provider Details

I. General information

NPI: 1952167355
Provider Name (Legal Business Name): SHOW ME STATE INFUSION CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/23/2024
Last Update Date: 02/23/2024
Certification Date: 02/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1704 BROADWAY ST # UNITE104
CAPE GIRARDEAU MO
63701-4580
US

IV. Provider business mailing address

1704 BROADWAY ST # UNITE104
CAPE GIRARDEAU MO
63701-4580
US

V. Phone/Fax

Practice location:
  • Phone: 573-307-9070
  • Fax:
Mailing address:
  • Phone: 573-307-9070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QI0500X
TaxonomyInfusion Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROSS VOGEL
Title or Position: OWNER
Credential:
Phone: 573-307-9070