Healthcare Provider Details

I. General information

NPI: 1205154606
Provider Name (Legal Business Name): HOLDEN FAMILY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2010
Last Update Date: 04/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

612 E 10TH ST
HOLDEN MO
64040-9421
US

IV. Provider business mailing address

612 E 10TH ST
HOLDEN MO
64040-9421
US

V. Phone/Fax

Practice location:
  • Phone: 816-732-6010
  • Fax: 816-732-6011
Mailing address:
  • Phone: 816-732-6010
  • Fax: 816-732-6011

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number076670
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number076670
License Number StateMO

VIII. Authorized Official

Name: MS. CAROL JEAN JACKSON
Title or Position: OFFICE MANAGER
Credential:
Phone: 816-732-6010