Healthcare Provider Details

I. General information

NPI: 1851860498
Provider Name (Legal Business Name): EXCELSIOR SPRINGS PHYSICIAN CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/13/2018
Last Update Date: 11/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

25610 PARK RD N
LAWSON MO
64062-8938
US

IV. Provider business mailing address

1700 RAINBOW BLVD
EXCELSIOR SPRINGS MO
64024-1182
US

V. Phone/Fax

Practice location:
  • Phone: 816-630-6722
  • Fax:
Mailing address:
  • Phone: 816-630-6081
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QS1000X
TaxonomyStudent Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: CAMERON MEYER
Title or Position: CFO
Credential:
Phone: 816-629-2763