Healthcare Provider Details

I. General information

NPI: 1740674340
Provider Name (Legal Business Name): MIDWEST SINUS ALLERGY INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/23/2015
Last Update Date: 03/23/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3315 BERRYWOOD DR STE. 207
COLUMBIA MO
65201-6571
US

IV. Provider business mailing address

3315 BERRYWOOD DR STE. 207
COLUMBIA MO
65201-6571
US

V. Phone/Fax

Practice location:
  • Phone: 573-815-0662
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number36516
License Number StateMO

VIII. Authorized Official

Name: MISS LINDSAY KETCHUM
Title or Position: OFFICE MANAGER
Credential:
Phone: 573-815-0662