Healthcare Provider Details

I. General information

NPI: 1558642496
Provider Name (Legal Business Name): ADELA CASA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2011
Last Update Date: 09/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

204 N CEDAR ST
NEVADA MO
64772-2310
US

IV. Provider business mailing address

PO BOX 1136
ANDERSON MO
64831-1136
US

V. Phone/Fax

Practice location:
  • Phone: 417-549-6845
  • Fax: 417-549-6836
Mailing address:
  • Phone: 417-845-2246
  • Fax: 417-845-2533

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2011014523
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: