Healthcare Provider Details

I. General information

NPI: 1770608135
Provider Name (Legal Business Name): KCMOSD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/21/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3221 INDIANA AVE
KANSAS CITY MO
64128-2062
US

IV. Provider business mailing address

1215 E TRUMAN RD
KANSAS CITY MO
64106-3152
US

V. Phone/Fax

Practice location:
  • Phone: 816-418-2075
  • Fax:
Mailing address:
  • Phone: 816-418-8653
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State

VIII. Authorized Official

Name: KCMO SD
Title or Position: CLINIC
Credential:
Phone: 816-418-8653