Healthcare Provider Details

I. General information

NPI: 1467462010
Provider Name (Legal Business Name): SSM AUDRAIN HEALTH CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/08/2006
Last Update Date: 05/08/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

626 E SUMMIT ST STE L
MEXICO MO
65265-3298
US

IV. Provider business mailing address

626 E SUMMIT ST STE L
MEXICO MO
65265-3298
US

V. Phone/Fax

Practice location:
  • Phone: 573-581-6266
  • Fax: 573-581-0955
Mailing address:
  • Phone: 573-581-6266
  • Fax: 573-581-0955

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MR. ROBERT V. VANCONIA
Title or Position: PRESIDENT/CEO
Credential:
Phone: 573-582-8108