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1375 Nettleton Avenue Thayer MO 65791 | |
(417) 264-7136 | |
(417) 264-7122 |
Full Name | |
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Speciality | Clinic/Center |
Location | 1375 Nettleton Avenue, Thayer, Missouri |
Authorized Official Name and Position | Thomas Keller (CEO/PRESIDENT) |
Authorized Official Contact | 4172569111 |
Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
Mailing Address | Practice Location Address |
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1375 Nettleton Ave Thayer MO 65791-8740 Ph: (417) 264-7136 | 1375 Nettleton Avenue Thayer MO 65791 Ph: (417) 264-7136 |
NPI Number | 1730215195 |
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Provider Enumeration Date | 02/27/2007 |
Last Update Date | 11/13/2020 |
Medicare PECOS PAC ID | 3870491863 |
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Medicare Enrollment ID | O20071217000346 |
Identifier | Type | State | Issuer |
---|---|---|---|
1730215195 | NPI | - | NPPES |
126733729 | Medicaid | AR | |
597843309 | Medicaid | MO |
Taxonomy | Type | License (State) | Status |
---|---|---|---|
261QR1300X | Clinic/center - Rural Health | 17447 (Missouri) | Primary |