Healthcare Provider Details

I. General information

NPI: 1205813417
Provider Name (Legal Business Name): ROSE F KINERK MW
Entity Type: Individual
Gender: Female
Sole Proprietor: X

Provider Other Name: ROSE F KALLENBACH

II. Dates (important events)

Enumeration Date: 12/29/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 S PERSHING AVE
SALEM MO
65560-1845
US

IV. Provider business mailing address

901 WILLIAM AVE
SALEM MO
65560-1082
US

V. Phone/Fax

Practice location:
  • Phone: 573-729-6222
  • Fax: 573-729-0094
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number002094
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: