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General NPI Number Information
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NPI Number | 1386126308
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Entity Type | Organization
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Legal Business Name | KIRKSVILLE SPECIALTY CLINIC LLC
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Dates
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Enumeration Date | 09/06/2018
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Last Update Date | 02/11/2020
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Provider Practice Location Address
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Address Line | 1108 E PATTERSON ST STE 10
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City | KIRKSVILLE
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State | MO
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Zip | 63501-4043
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Country | US
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Telephone | 660-956-0487
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Fax | 660-956-0446
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Provider Business Mailing Address
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Address Line | 1108 E PATTERSON ST STE 10
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City | KIRKSVILLE
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State | MO
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Zip | 63501-4043
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Country | US
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Telephone | 660-956-0487
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Fax | 660-956-0446
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Authorized Official
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Title or Position | CEO
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Name | MR. DAVID NEUENDORF
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Credential |
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Telephone | 573-886-8904
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM2500X
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Taxonomy Name | Medical Specialty Clinic/Center
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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 | 207RR0500X
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Taxonomy Name | Rheumatology Physician
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License Number | R6C73
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License Number State | MO
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