Healthcare Provider Details

I. General information

NPI: 1265730246
Provider Name (Legal Business Name): DEKALB COUNTY SENATE BILL 40
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/01/2011
Last Update Date: 03/01/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

113 EAST MAIN
MAYSVILLE MO
64494
US

IV. Provider business mailing address

PO BOX 514
MAYSVILLE MO
64469-0514
US

V. Phone/Fax

Practice location:
  • Phone: 816-449-2200
  • Fax:
Mailing address:
  • Phone: 816-449-2200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. RON CRIDER
Title or Position: CHAIRPERSON
Credential:
Phone: 816-449-5481