Healthcare Provider Details

I. General information

NPI: 1124057112
Provider Name (Legal Business Name): SOUTHTOWNE URGENT CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

180 MALL RD SUITE H
HOLLISTER MO
65672-9602
US

IV. Provider business mailing address

180 MALL RD SUITE H
HOLLISTER MO
65672-9602
US

V. Phone/Fax

Practice location:
  • Phone: 417-336-5161
  • Fax: 417-336-0242
Mailing address:
  • Phone: 417-336-5161
  • Fax: 417-336-0242

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License NumberR5F63
License Number StateMO

VIII. Authorized Official

Name: DR. BRIAN TEETER
Title or Position: OFFICER
Credential: M.D.
Phone: 417-336-5161