Healthcare Provider Details

I. General information

NPI: 1144004821
Provider Name (Legal Business Name): ZIVA MEDICAL PRIMARY CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2023
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E PROMENADE ST STE 1
MEXICO MO
65265-2966
US

IV. Provider business mailing address

PO BOX 197
LAKEWOOD NJ
08701-0197
US

V. Phone/Fax

Practice location:
  • Phone: 573-570-3520
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: AMANDA SHURTZ
Title or Position: CEO
Credential:
Phone: 573-570-3555