Healthcare Provider Details

I. General information

NPI: 1881607612
Provider Name (Legal Business Name): FORDLAND CLINIC, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/14/2006
Last Update Date: 06/19/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1059 BARTON DR
FORDLAND MO
65652-7350
US

IV. Provider business mailing address

1059 BARTON DR
FORDLAND MO
65652-7350
US

V. Phone/Fax

Practice location:
  • Phone: 417-767-2273
  • Fax: 417-767-4054
Mailing address:
  • Phone: 417-767-2273
  • Fax: 417-767-4054

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number263865
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number26-1009
License Number StateMO

VIII. Authorized Official

Name: JOAN TWITON
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 417-767-2273