Healthcare Provider Details

I. General information

NPI: 1194908632
Provider Name (Legal Business Name): FLAT CREEK ENTERPRISES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 04/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1410 E KEARNEY ST SUITE D
SPRINGFIELD MO
65803-4102
US

IV. Provider business mailing address

PO BOX 8235
SPRINGFIELD MO
65801-8235
US

V. Phone/Fax

Practice location:
  • Phone: 417-773-0520
  • Fax:
Mailing address:
  • Phone: 417-864-5455
  • Fax: 417-864-5781

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number114747
License Number StateMO

VIII. Authorized Official

Name: DR. DAVE D WEEMS
Title or Position: OWNER
Credential: D.O.
Phone: 417-773-0520