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General NPI Number Information
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NPI Number | 1578712741
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Entity Type | Organization
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Legal Business Name | JOHN J PERSHING VA MEDICAL CENTER
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Dates
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Enumeration Date | 09/12/2008
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Last Update Date | 09/12/2008
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Provider Practice Location Address
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Address Line | 1500 N WESTWOOD BLVD
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-3318
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Country | US
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Telephone | 573-778-4244
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Fax | 573-778-4153
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Provider Business Mailing Address
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Address Line | 1500 N WESTWOOD BLVD
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City | POPLAR BLUFF
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State | MO
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Zip | 63901-3318
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Country | US
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Telephone | 573-778-4244
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Fax | 573-778-4153
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Authorized Official
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Title or Position | LEAD MEDICAL TECHNOLOGIST
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Name | MISS TRACIE A EUDALEY
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Credential | M.T.
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Telephone | 573-778-4244
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 291U00000X
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Taxonomy Name | Clinical Medical Laboratory
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License Number | 176313
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License Number State | MO
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