MEDICARE: DOUGLAS COUNTY HEALTH DEPARTMENT

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	261QP0905X	State or Local Public Health Clinic/Center

General Provider Information

NPI Number	:	1649253105
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DOUGLAS COUNTY HEALTH DEPARTMENT

Provider Business Mailing Address
First Line	:	PO BOX 940
Second Line	:	BUILDING C
City	:	AVA
State	:	MO
Zip	:	65608-0940
Country	:	US
Telephone Number	:	417-683-4174
Fax Number	:	417-683-4111

Provider Business Practice Location Address
First Line	:	603 NW 12TH ST
Second Line	:	BUILDING C
City	:	AVA
State	:	MO
Zip	:	65608-0940
Country	:	US
Telephone Number	:	417-683-4174
Fax Number	:	417-683-4111

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	SANDRA PUEPPKE
Credential	:
Telephone Number	:	417-683-4174

Provider Enumeration Date	:	11/29/2005
Last Update Date	:	08/22/2020

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Directions to “DOUGLAS COUNTY HEALTH DEPARTMENT ” Practice Location

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