Healthcare Provider Details

I. General information

NPI: 1336679836
Provider Name (Legal Business Name): NORTHEAST MISSOURI HEALTH COUNCIL INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/16/2017
Last Update Date: 07/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 CROWN DR
KIRKSVILLE MO
63501-2548
US

IV. Provider business mailing address

1416 CROWN DR
KIRKSVILLE MO
63501-2548
US

V. Phone/Fax

Practice location:
  • Phone: 660-627-4493
  • Fax:
Mailing address:
  • Phone: 660-627-5757
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103T00000X
TaxonomyPsychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: ANDREW GRIMM
Title or Position: CEO
Credential:
Phone: 660-627-5757