Healthcare Provider Details

I. General information

NPI: 1023210648
Provider Name (Legal Business Name): MISSISSIPPI COUNTY HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/05/2007
Last Update Date: 12/07/2023
Certification Date: 12/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 E MARSHALL ST
CHARLESTON MO
63834-1336
US

IV. Provider business mailing address

1200 E MARSHALL ST
CHARLESTON MO
63834-1336
US

V. Phone/Fax

Practice location:
  • Phone: 573-683-2191
  • Fax: 573-683-6539
Mailing address:
  • Phone: 573-683-2191
  • Fax: 573-683-6539

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number126551
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number33173
License Number StateMO

VIII. Authorized Official

Name: RACHELLE JOHNSON
Title or Position: ADMINISTRATOR
Credential: RD, LD, CDE
Phone: 573-683-2191