Healthcare Provider Details

I. General information

NPI: 1104804699
Provider Name (Legal Business Name): KNEIBERT CLINIC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/04/2006
Last Update Date: 03/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

686 LESTER ST
POPLAR BLUFF MO
63901
US

IV. Provider business mailing address

PO BOX 220
POPLAR BLUFF MO
63902
US

V. Phone/Fax

Practice location:
  • Phone: 573-686-2411
  • Fax: 573-686-8452
Mailing address:
  • Phone: 573-686-2411
  • Fax: 573-686-8452

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code261QR1300X
TaxonomyRural Health Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: ROBERT E CHRISTIAN
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-778-7210