MEDICARE: C. TUCKER JOUSTRA FAMILY PRACTICE, INC.

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	261QP2300X	Primary Care Clinic/Center	R9G86	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609108240
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	C. TUCKER JOUSTRA FAMILY PRACTICE, INC.

Provider Business Mailing Address
First Line	:	805 GULF ST
Second Line	:
City	:	LAMAR
State	:	MO
Zip	:	64759-1238
Country	:	US
Telephone Number	:	417-682-5508
Fax Number	:	417-682-5594

Provider Business Practice Location Address
First Line	:	805 GULF ST
Second Line	:
City	:	LAMAR
State	:	MO
Zip	:	64759-1238
Country	:	US
Telephone Number	:	417-682-5508
Fax Number	:	417-682-5594

Authorized Official
Title or Position	:	PRESIDENT
Name	:	CLARENCE TUCKER JOUSTRA
Credential	:	D.O.
Telephone Number	:	417-682-5508

Provider Enumeration Date	:	02/08/2010
Last Update Date	:	02/08/2010

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Directions to “C. TUCKER JOUSTRA FAMILY PRACTICE, INC. ” Practice Location

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