Healthcare Provider Details

I. General information

NPI: 1750697322
Provider Name (Legal Business Name): CARTER P FENTON SR CLINICS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/20/2010
Last Update Date: 04/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

206 S MAIN ST
CHAFFEE MO
63740-1002
US

IV. Provider business mailing address

PO BOX 98
CHAFFEE MO
63740-0098
US

V. Phone/Fax

Practice location:
  • Phone: 573-887-3688
  • Fax: 573-887-9022
Mailing address:
  • Phone: 573-887-3688
  • Fax: 573-887-9022

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number31606
License Number StateMO

VIII. Authorized Official

Name: CARTER P FENTON
Title or Position: PRESIDENT
Credential: DO
Phone: 573-887-3688