Healthcare Provider Details

I. General information

NPI: 1073767521
Provider Name (Legal Business Name): OCCUPATIONAL MEDICINE OF NORTHWEST MISSOURI, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2008
Last Update Date: 11/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

904 EDMOND ST
SAINT JOSEPH MO
64501-2702
US

IV. Provider business mailing address

PO BOX 877674
KANSAS CITY MO
64187-7674
US

V. Phone/Fax

Practice location:
  • Phone: 816-233-7702
  • Fax:
Mailing address:
  • Phone: 816-561-2105
  • Fax: 816-559-6383

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License NumberLC0928916
License Number StateMO

VIII. Authorized Official

Name: MS. MELINDA WAGNER
Title or Position: CHIEF OPERATIONS OFFICER
Credential:
Phone: 816-559-6301