Healthcare Provider Details

I. General information

NPI: 1780603969
Provider Name (Legal Business Name): LETASSY HEALTH SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 10/08/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1002 W PINE ST
POPLAR BLUFF MO
63901-4840
US

IV. Provider business mailing address

1002 W PINE ST
POPLAR BLUFF MO
63901-4840
US

V. Phone/Fax

Practice location:
  • Phone: 573-785-0048
  • Fax: 573-785-0459
Mailing address:
  • Phone: 573-785-0048
  • Fax: 573-785-0459

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number854887502
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code332BN1400X
TaxonomyNursing Facility Supplies (DME)
License Number622577708
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number004918
License Number StateMO

VIII. Authorized Official

Name: DR. DAVID T LETASSY
Title or Position: RPH
Credential:
Phone: 573-785-0048