=====================================================
General NPI Number Information
=====================================================
NPI Number | 1427771922
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAPE FAMILY MEDICAL CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2022
-----------------------------------------------------
Last Update Date | 09/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 8 N FRENCH LN
-----------------------------------------------------
City | PERRYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63775-1577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 573-332-7992
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8 N FRENCH LN
-----------------------------------------------------
City | PERRYVILLE
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 63775-1577
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | AMELIA DORIS LEDBETTER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 573-335-4715
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------