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General NPI Number Information
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NPI Number | 1114117306
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Entity Type | Organization
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Legal Business Name | DOCTORS INN CLINIC LLC
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Dates
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Enumeration Date | 07/25/2007
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Last Update Date | 02/26/2010
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Provider Practice Location Address
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Address Line | 1112 SOUTH BYP STE C SUITE C
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City | KENNETT
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State | MO
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Zip | 63857-3738
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Country | US
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Telephone | 573-717-1776
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Fax | 573-717-1572
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Provider Business Mailing Address
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Address Line | 1112 SOUTH BYP SUITE C
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City | KENNETT
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State | MO
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Zip | 63857-3738
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Country | US
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Telephone | 573-717-1776
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Fax | 573-717-1572
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Authorized Official
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Title or Position | NP
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Name | DEBBIE A WADE
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Credential | NP
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Telephone | 573-717-1776
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number | 2000148413
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License Number State | MO
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