MEDICARE: CLARK COUNTY NURSING SERVICE & HOME HEALTH AGENCY

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	376J00000X	Homemaker		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	:	1629261680
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CLARK COUNTY NURSING SERVICE & HOME HEALTH AGENCY

Provider Business Mailing Address
First Line	:	670 N JOHNSON ST
Second Line	:	P O BOX 12
City	:	KAHOKA
State	:	MO
Zip	:	63445-1430
Country	:	US
Telephone Number	:	660-727-2356
Fax Number	:

Provider Business Practice Location Address
First Line	:	670 N JOHNSON ST
Second Line	:
City	:	KAHOKA
State	:	MO
Zip	:	63445-1430
Country	:	US
Telephone Number	:	660-727-2356
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. M EVELENA SUTTERFIELD
Credential	:	RN
Telephone Number	:	660-727-2356

Provider Enumeration Date	:	08/23/2007
Last Update Date	:	03/26/2013

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