=====================================================
General NPI Number Information
=====================================================
NPI Number | 1699173757
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ICARE PRIMARY CARE CLINIC, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2014
-----------------------------------------------------
Last Update Date | 12/05/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 550 RUSH CREEK PKWY SUITE B
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-9608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-875-4325
-----------------------------------------------------
Fax | 636-237-8053
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 550 RUSH CREEK PKWY SUITE B
-----------------------------------------------------
City | LIBERTY
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 64068-9608
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 816-875-4325
-----------------------------------------------------
Fax | 636-237-8053
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF MEDICAL OFFICER
-----------------------------------------------------
Name | DR. ERIK CHRISTIAN PETERSEN
-----------------------------------------------------
Credential | D.O.
-----------------------------------------------------
Telephone | 816-875-4325
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 324500000X
-----------------------------------------------------
Taxonomy Name | Substance Abuse Rehabilitation Facility
-----------------------------------------------------
License Number | FL001411027
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------