Healthcare Provider Details

I. General information

NPI: 1881346658
Provider Name (Legal Business Name): CHILLICOTHE WOMENS CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 05/17/2022
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 FAIRWAY DR
CHILLICOTHEE MO
64601-3673
US

IV. Provider business mailing address

4566 STATE HIGHWAY 190
CHILLICOTHEE MO
64601-5313
US

V. Phone/Fax

Practice location:
  • Phone: 913-680-9830
  • Fax:
Mailing address:
  • Phone: 913-680-9830
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. YULIA PENISTON
Title or Position: PHYSICIAN
Credential: DO
Phone: 913-680-9830