=====================================================
General NPI Number Information
=====================================================
NPI Number | 1316658495
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DISSOCIATIVE ASSOCIATES, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/08/2022
-----------------------------------------------------
Last Update Date | 12/08/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 817 NE ANDERSON LN
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64064-1244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-381-2050
-----------------------------------------------------
Fax | 816-503-8271
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 817 NE ANDERSON LN
-----------------------------------------------------
City | LEES SUMMIT
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64064-1244
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-381-2050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OFFICE MANAGER
-----------------------------------------------------
Name | ROBERT FANSLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 816-678-5969
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QI0500X
-----------------------------------------------------
Taxonomy Name | Infusion Therapy Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------