Healthcare Provider Details

I. General information

NPI: 1083705529
Provider Name (Legal Business Name): FAMILY WALK IN CLINIC OF MOUNTAIN GROVE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 11/12/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

205 W 3RD ST STE 3
MOUNTAIN GROVE MO
65711-1600
US

IV. Provider business mailing address

205 W 3RD ST STE 3
MOUNTAIN GROVE MO
65711-1600
US

V. Phone/Fax

Practice location:
  • Phone: 417-926-3743
  • Fax: 417-926-7625
Mailing address:
  • Phone: 417-926-3743
  • Fax: 417-926-7625

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. KENNETH H DUGAN
Title or Position: VICE-PRESIDENT
Credential: M.D.
Phone: 417-926-3743