Healthcare Provider Details

I. General information

NPI: 1992615371
Provider Name (Legal Business Name): MISSOURI VALLEY MEDICAL CENTER, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/09/2026
Last Update Date: 09/09/2026
Certification Date: 09/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2303 S HIGHWAY 65
MARSHALL MO
65340-3734
US

IV. Provider business mailing address

1869 CRAIG PARK CT
SAINT LOUIS MO
63146-4122
US

V. Phone/Fax

Practice location:
  • Phone: 660-886-7800
  • Fax: 660-886-6044
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS DESTEFANE
Title or Position: AUTHORIZED SIGNATORY
Credential:
Phone: 314-543-3800