Healthcare Provider Details

I. General information

NPI: 1619648532
Provider Name (Legal Business Name): BOONE PHYSICIAN SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1021 E HIGHWAY 22
CENTRALIA MO
65240-1183
US

IV. Provider business mailing address

1021 E HIGHWAY 22
CENTRALIA MO
65240-1183
US

V. Phone/Fax

Practice location:
  • Phone: 573-682-5588
  • Fax: 573-682-1539
Mailing address:
  • Phone: 573-682-5588
  • Fax: 573-682-1539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BRIAN LEE WINN
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 573-815-3269