Healthcare Provider Details

I. General information

NPI: 1639252968
Provider Name (Legal Business Name): IMMEDIATE HEALTHCARE KINGS HIGHWAY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/23/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1702 N KINGSHIGHWAY ST
CAPE GIRARDEAU MO
63701-2122
US

IV. Provider business mailing address

1702 N KINGSHIGHWAY ST
CAPE GIRARDEAU MO
63701-2122
US

V. Phone/Fax

Practice location:
  • Phone: 573-339-2000
  • Fax: 573-339-1876
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License NumberR2J89
License Number StateMO

VIII. Authorized Official

Name: DIRENDIA SHACKELFORD
Title or Position: MANAGED CARE SPECIALIST
Credential:
Phone: 800-654-0889