MEDICARE: 417 HEALTH CARE

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1689321218
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	417 HEALTH CARE

Provider Business Mailing Address
First Line	:	830 W MOUNT VERNON ST STE 10
Second Line	:
City	:	NIXA
State	:	MO
Zip	:	65714-9615
Country	:	US
Telephone Number	:	417-374-4141
Fax Number	:	417-374-4140

Provider Business Practice Location Address
First Line	:	830 W MOUNT VERNON ST STE 10
Second Line	:
City	:	NIXA
State	:	MO
Zip	:	65714-9615
Country	:	US
Telephone Number	:	417-374-4141
Fax Number	:	417-374-4140

Authorized Official
Title or Position	:	OWNER
Name	:	DAINA KAYS
Credential	:	FNP
Telephone Number	:	417-374-4141

Provider Enumeration Date	:	03/03/2022
Last Update Date	:	03/03/2022

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Directions to “417 HEALTH CARE ” Practice Location

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