Healthcare Provider Details

I. General information

NPI: 1427051069
Provider Name (Legal Business Name): PHELPS COUNTY CLERK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/27/2005
Last Update Date: 08/15/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 N MAIN ST STE G51
ROLLA MO
65401-3070
US

IV. Provider business mailing address

200 N MAIN ST STE G51
ROLLA MO
65401-3070
US

V. Phone/Fax

Practice location:
  • Phone: 573-458-6010
  • Fax: 573-458-6060
Mailing address:
  • Phone: 573-458-6010
  • Fax: 573-458-6060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0905X
TaxonomyState or Local Public Health Clinic/Center
License NumberN/A
License Number StateMO

VIII. Authorized Official

Name: JOSEPHINE P WALTMAN
Title or Position: ADMINISTRATOR
Credential: MS, MED, CPNP
Phone: 573-458-6010