Healthcare Provider Details

I. General information

NPI: 1588643480
Provider Name (Legal Business Name): BONNIE J RIVERS MS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/10/2006
Last Update Date: 01/17/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N 2ND ST
ODESSA MO
64076-1137
US

IV. Provider business mailing address

301 N 2ND ST
ODESSA MO
64076-1137
US

V. Phone/Fax

Practice location:
  • Phone: 816-633-5921
  • Fax: 816-633-7942
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number002133
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: