MEDICARE: IHC OF MID MISSOURI, LLC

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	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1619410198
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	IHC OF MID MISSOURI, LLC

Provider Business Mailing Address
First Line	:	13725 METCALF AVE
Second Line	:	SUITE 411
City	:	OVERLAND PARK
State	:	KS
Zip	:	66223-7899
Country	:	US
Telephone Number	:	210-213-0248
Fax Number	:

Provider Business Practice Location Address
First Line	:	303 N STADIUM BLVD
Second Line	:	2ND FLOOR
City	:	COLUMBIA
State	:	MO
Zip	:	65203-1493
Country	:	US
Telephone Number	:	573-458-5330
Fax Number	:	877-240-6523

Authorized Official
Title or Position	:	DIRECTOR OF OPERATIONS
Name	:	GARY BODONY
Credential	:
Telephone Number	:	573-458-5990

Provider Enumeration Date	:	12/01/2016
Last Update Date	:	12/01/2016

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