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General NPI Number Information
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NPI Number | 1043455272
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Entity Type | Organization
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Legal Business Name | SB40 TCM
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Dates
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Enumeration Date | 12/02/2008
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Last Update Date | 12/02/2008
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Provider Practice Location Address
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Address Line | HC 1 BOX 2
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City | MIDDLE BROOK
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State | MO
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Zip | 63656-9701
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Country | US
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Telephone | 573-546-3981
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 278
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City | IRONTON
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State | MO
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Zip | 63650-0278
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Country | US
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Telephone | 573-546-3981
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MR. GARY WAYNE PHEGLEY
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Credential |
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Telephone | 573-546-3981
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251B00000X
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Taxonomy Name | Case Management Agency
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License Number |
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License Number State | MO
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