Healthcare Provider Details

I. General information

NPI: 1730208646
Provider Name (Legal Business Name): JORGEN C WIBSKOV HIS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/29/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 POTOSI ST STE A
FARMINGTON MO
63640-2436
US

IV. Provider business mailing address

310 POTOSI ST STE A
FARMINGTON MO
63640-2436
US

V. Phone/Fax

Practice location:
  • Phone: 573-756-1919
  • Fax: 573-756-9089
Mailing address:
  • Phone: 573-756-1919
  • Fax: 573-756-9089

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number1040
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: