Healthcare Provider Details

I. General information

NPI: 1437270915
Provider Name (Legal Business Name): NORTHWEST HEALTH SERVICES, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2007
Last Update Date: 11/10/2021
Certification Date: 11/10/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1303 STATE STREET
MOUND CITY MO
64470-1717
US

IV. Provider business mailing address

1303 STATE STREET
MOUND CITY MO
64470-1717
US

V. Phone/Fax

Practice location:
  • Phone: 660-442-5464
  • Fax: 660-442-5927
Mailing address:
  • Phone: 660-442-5464
  • Fax: 660-442-5927

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number StateNULL

VIII. Authorized Official

Name: MATT YOUNGER
Title or Position: CEO
Credential:
Phone: 816-232-6818