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General NPI Number Information
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NPI Number | 1104476928
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Entity Type | Organization
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Legal Business Name | COMPLEX HEALTHCARE OF FARMINGTON LLC
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Dates
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Enumeration Date | 09/13/2019
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Last Update Date | 08/23/2022
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Provider Practice Location Address
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Address Line | 555 W PINE ST
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City | FARMINGTON
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State | MO
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Zip | 63640-1439
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Country | US
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Telephone | 573-223-8600
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Fax |
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Provider Business Mailing Address
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Address Line | 4201 INTERWAY PL
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City | ARLINGTON
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State | TX
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Zip | 76018-5668
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Country | US
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Telephone | 817-687-8014
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | GLENN HERMES
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Credential |
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Telephone | 817-692-6313
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207PE0005X
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Taxonomy Name | Undersea and Hyperbaric Medicine (Emergency Medicine) Physician
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License Number |
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License Number State |
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