Healthcare Provider Details

I. General information

NPI: 1801952833
Provider Name (Legal Business Name): WESTERN JOHNSON COUNTY MEDICAL CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2006
Last Update Date: 09/07/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 E PACIFIC ST
KINGSVILLE MO
64061-2512
US

IV. Provider business mailing address

305 E PACIFIC ST
KINGSVILLE MO
64061-2512
US

V. Phone/Fax

Practice location:
  • Phone: 816-597-3500
  • Fax: 816-597-3555
Mailing address:
  • Phone: 816-597-3500
  • Fax: 816-597-3555

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: WENDY BLAYLOCK
Title or Position: OFFICE MANAGER
Credential:
Phone: 816-597-3500