Healthcare Provider Details

I. General information

NPI: 1609655323
Provider Name (Legal Business Name): ZIVA MEDICAL AUDRAIN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2023
Last Update Date: 11/30/2023
Certification Date: 11/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

515 E PROMENADE ST # A
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: 573-675-6040
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

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