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401 W Pettis St Green Ridge MO 65332-1160 | |
(877) 733-5824 | |
(888) 979-8868 |
Full Name | |
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Speciality | Clinic/Center |
Location | 401 W Pettis St, Green Ridge, Missouri |
Authorized Official Name and Position | Michael Waller (CEO) |
Authorized Official Contact | 8777335824 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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821 Westwood Dr Sedalia MO 65301-2102 Ph: (660) 826-4774 | 401 W Pettis St Green Ridge MO 65332-1160 Ph: (877) 733-5824 |
NPI Number | 1417599556 |
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Provider Enumeration Date | 10/10/2019 |
Last Update Date | 02/21/2024 |
Medicare PECOS PAC ID | 8224926092 |
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Medicare Enrollment ID | O20200401001100 |
Identifier | Type | State | Issuer |
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1417599556 | NPI | - | NPPES |
Taxonomy | Type | License (State) | Status |
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261QF0400X | Clinic/center - Federally Qualified Health Center (fqhc) | (* (Not Available)) | Primary |