Healthcare Provider Details

I. General information

NPI: 1689183881
Provider Name (Legal Business Name): COMMUNITY HOSPITAL ASSOCIATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 E MAIN ST
FAIRFAX MO
64446-9312
US

IV. Provider business mailing address

26136 US HIGHWAY 59
FAIRFAX MO
64446-9105
US

V. Phone/Fax

Practice location:
  • Phone: 660-686-0263
  • Fax: 660-686-0262
Mailing address:
  • Phone: 660-686-2211
  • Fax: 660-686-2618

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JON P DAVIS
Title or Position: CFO
Credential:
Phone: 660-686-2320