Healthcare Provider Details

I. General information

NPI: 1861875684
Provider Name (Legal Business Name): GOLDEN VALLEY MEMORIAL HOSPITAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/30/2015
Last Update Date: 06/30/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 N 2ND ST
CLINTON MO
64735-1192
US

IV. Provider business mailing address

1602 N 2ND ST
CLINTON MO
64735-1192
US

V. Phone/Fax

Practice location:
  • Phone: 660-885-8171
  • Fax: 660-890-8013
Mailing address:
  • Phone: 660-885-8171
  • Fax: 660-890-8013

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2014022519
License Number StateMO

VIII. Authorized Official

Name: KYLE D ADKINS
Title or Position: ADMINISTRATOR
Credential:
Phone: 660-885-8171