MEDICARE: VILLAGE OF CLAYCOMO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	3416L0300X	Land Ambulance

General Provider Information

NPI Number	:	1083648711
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	VILLAGE OF CLAYCOMO

Provider Business Mailing Address
First Line	:	333 E 69 HIGHWAY
Second Line	:
City	:	CLAYCOMO
State	:	MO
Zip	:	64119
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 E 69 HIGHWAY
Second Line	:
City	:	CLAYCOMO
State	:	MO
Zip	:	64119
Country	:	US
Telephone Number	:	816-452-4612
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	BRUCE BUTLER
Credential	:
Telephone Number	:	816-452-4612

Provider Enumeration Date	:	07/10/2006
Last Update Date	:	03/07/2012

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