Healthcare Provider Details

I. General information

NPI: 1467519058
Provider Name (Legal Business Name): WESTON FAMILY CLINIC, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/02/2007
Last Update Date: 10/12/2020
Certification Date: 10/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18215 STATE ROUTE 45 N
WESTON MO
64098-9101
US

IV. Provider business mailing address

PO BOX 40
WESTON MO
64098-0040
US

V. Phone/Fax

Practice location:
  • Phone: 816-640-2762
  • Fax: 816-640-5564
Mailing address:
  • Phone: 816-640-2762
  • Fax: 816-640-5564

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberR1J75
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: JANICE E CHENOWETH
Title or Position: OFFICE MANAGER
Credential:
Phone: 816-640-2762