Healthcare Provider Details

I. General information

NPI: 1750422457
Provider Name (Legal Business Name): SALT RIVER COMMUNITY HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 07/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3145 HIGHWAY 61
HANNIBAL MO
63401-6588
US

IV. Provider business mailing address

3145 HIGHWAY 61
HANNIBAL MO
63401-6588
US

V. Phone/Fax

Practice location:
  • Phone: 573-221-1166
  • Fax: 573-221-1214
Mailing address:
  • Phone: 573-221-4422
  • Fax: 573-221-4470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QC1500X
TaxonomyCommunity Health Clinic/Center
License Number19782870
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number19782870
License Number StateMO

VIII. Authorized Official

Name: JOAN F HYNEK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 573-221-4422