Healthcare Provider Details

I. General information

NPI: 1730359340
Provider Name (Legal Business Name): KIRKSVILLE ALLERGY AND ASTHMA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/11/2008
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 ROSEWOOD DR
KIRKSVILLE MO
63501-2477
US

IV. Provider business mailing address

610 ROSEWOOD DR
KIRKSVILLE MO
63501-2477
US

V. Phone/Fax

Practice location:
  • Phone: 660-627-2553
  • Fax: 660-665-0448
Mailing address:
  • Phone: 660-627-2553
  • Fax: 660-665-0448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207KA0200X
TaxonomyAllergy Physician
License Number19139861
License Number StateMO

VIII. Authorized Official

Name: MRS. TRACY TALTON
Title or Position: CLINIC MANAGER
Credential:
Phone: 660-627-2553