Healthcare Provider Details

I. General information

NPI: 1861948697
Provider Name (Legal Business Name): MIDWEST HEALTH GROUP CONVENIENT CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/31/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 N MINE LA MOTTE ST
FREDERICKTOWN MO
63645-1201
US

IV. Provider business mailing address

123 N. MINE LAMOTTE
FREDERICKTOWN MO
63640
US

V. Phone/Fax

Practice location:
  • Phone: 573-561-1334
  • Fax: 573-561-1335
Mailing address:
  • Phone: 573-561-1334
  • Fax: 573-561-1335

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332900000X
TaxonomyNon-Pharmacy Dispensing Site
License Number
License Number State

VIII. Authorized Official

Name: MRS. MARY ELIZABETH CHANDLER
Title or Position: MANAGER
Credential: FNP-C
Phone: 573-358-1700