Healthcare Provider Details

I. General information

NPI: 1104192749
Provider Name (Legal Business Name): CENTRAL CARE, PA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/28/2012
Last Update Date: 02/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2828 N NATIONAL AVE SUITE A
SPRINGFIELD MO
65803-4306
US

IV. Provider business mailing address

PO BOX 256
SALINA KS
67402-0256
US

V. Phone/Fax

Practice location:
  • Phone: 417-875-4600
  • Fax: 417-875-4700
Mailing address:
  • Phone: 785-823-0633
  • Fax: 785-823-0658

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number002905
License Number StateMO

VIII. Authorized Official

Name: WENDY J LEITH
Title or Position: DIRECTOR OF BILLING
Credential:
Phone: 785-823-0633