Healthcare Provider Details

I. General information

NPI: 1972649986
Provider Name (Legal Business Name): NORTHEAST MISSOURI HEALTH COUNCIL, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2007
Last Update Date: 10/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

402 W JEFFERSON ST
KIRKSVILLE MO
63501-3407
US

IV. Provider business mailing address

1416 CROWN DR P O BOX 1027
KIRKSVILLE MO
63501-2548
US

V. Phone/Fax

Practice location:
  • Phone: 660-665-2741
  • Fax: 660-665-3109
Mailing address:
  • Phone: 660-627-5757
  • Fax: 660-627-5802

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number2001012903
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number2006007559
License Number StateMO
# 3
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number003847
License Number StateMO
# 4
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateMO

VIII. Authorized Official

Name: ANDREW H. GRIMM
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 660-627-5757