Healthcare Provider Details

I. General information

NPI: 1538281126
Provider Name (Legal Business Name): VAN FAR R-I
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/04/2007
Last Update Date: 08/01/2023
Certification Date: 08/01/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 W US HIGHWAY 54
VANDALIA MO
63382-1130
US

IV. Provider business mailing address

2200 W US HIGHWAY 54
VANDALIA MO
63382-1130
US

V. Phone/Fax

Practice location:
  • Phone: 573-594-6111
  • Fax: 573-594-2878
Mailing address:
  • Phone: 573-594-6111
  • Fax: 573-594-2878

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251300000X
TaxonomyLocal Education Agency (LEA)
License Number
License Number State

VIII. Authorized Official

Name: MR. JOHN KENNETH FORTNEY
Title or Position: SUPERINTENDENT
Credential:
Phone: 573-594-6111