Healthcare Provider Details

I. General information

NPI: 1255048062
Provider Name (Legal Business Name): ENCORE PEDIATRICS OF MISSOURI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 08/21/2024
Certification Date: 08/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

221 BOLIVAR ST
JEFFERSON CITY MO
65101-1572
US

IV. Provider business mailing address

33533 W 12 MILE RD STE 290
FARMINGTON HILLS MI
48331-5635
US

V. Phone/Fax

Practice location:
  • Phone: 866-925-8505
  • Fax:
Mailing address:
  • Phone: 216-202-8260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN COTCHER
Title or Position: EVP OF PEDIATRICS
Credential:
Phone: 248-672-2593