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General NPI Number Information
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NPI Number | 1649514050
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Entity Type | Organization
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Legal Business Name | CAPITAL REGION RESIDENT CLINIC
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Dates
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Enumeration Date | 11/26/2012
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Last Update Date | 06/10/2014
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Provider Practice Location Address
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Address Line | 220 MADISON ST.
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City | JEFFERSON CITY
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State | MO
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Zip | 65102
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Country | US
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Telephone | 573-632-4900
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Fax | 573-644-6650
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Provider Business Mailing Address
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Address Line | 1111 MADISON ST
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City | JEFFERSON CITY
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State | MO
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Zip | 65101-2753
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Country | US
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Telephone | 573-632-5027
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Fax | 573-634-5878
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Authorized Official
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Title or Position | VP OF FINANCE
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Name | TOM LUEBBERING
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Credential |
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Telephone | 573-632-5100
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number |
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License Number State |
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