=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730215195
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | OZARKS MEDICAL CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/27/2007
-----------------------------------------------------
Last Update Date | 11/13/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1375 NETTLETON AVENUE
-----------------------------------------------------
City | THAYER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65791
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-264-7136
-----------------------------------------------------
Fax | 417-264-7122
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1375 NETTLETON AVE
-----------------------------------------------------
City | THAYER
-----------------------------------------------------
State | MO
-----------------------------------------------------
Zip | 65791-8740
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 417-264-7136
-----------------------------------------------------
Fax | 417-264-7122
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO/PRESIDENT
-----------------------------------------------------
Name | THOMAS KELLER
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 417-256-9111
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR1300X
-----------------------------------------------------
Taxonomy Name | Rural Health Clinic/Center
-----------------------------------------------------
License Number | 17447
-----------------------------------------------------
License Number State | MO
-----------------------------------------------------