Healthcare Provider Details

I. General information

NPI: 1255492575
Provider Name (Legal Business Name): FOREST CITY FAMILY PRACTICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 02/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 N JEFFERSON ST
SAINT JAMES MO
65559-1078
US

IV. Provider business mailing address

1000 N JEFFERSON ST
SAINT JAMES MO
65559-1078
US

V. Phone/Fax

Practice location:
  • Phone: 573-265-8840
  • Fax: 573-265-8884
Mailing address:
  • Phone: 573-265-8840
  • Fax: 573-265-8884

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MS. KATHY KLEFFNER
Title or Position: BUSINESS OFFICE
Credential:
Phone: 573-265-8840