Healthcare Provider Details

I. General information

NPI: 1841261153
Provider Name (Legal Business Name): JCMG ANCILLARY SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 10/30/2023
Certification Date: 10/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1241 W STADIUM BLVD
JEFFERSON CITY MO
65109-6023
US

IV. Provider business mailing address

1241 W STADIUM BLVD
JEFFERSON CITY MO
65109-6023
US

V. Phone/Fax

Practice location:
  • Phone: 573-635-5264
  • Fax: 573-636-9756
Mailing address:
  • Phone: 573-635-5264
  • Fax: 573-636-9756

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR0200X
TaxonomyRadiology Clinic/Center
License Number0980220
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number26D0446044
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code333600000X
TaxonomyPharmacy
License Number006386
License Number StateMO

VIII. Authorized Official

Name: CASSIE CALL
Title or Position: CREDENTIALING
Credential:
Phone: 573-556-1783