Basic Information
| Provider Information | |||||||||
| NPI: | 1245479526 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAMILY HEALTH CENTER OF BOONE COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | FAMILY DENTAL CENTER AT SALISBURY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1001 W WORLEY ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBIA | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652032037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5738866741 | ||||||||
| FaxNumber: | 5736072885 | ||||||||
| Practice Location | |||||||||
| Address1: | 307 S BROADWAY | ||||||||
| Address2: | |||||||||
| City: | SALISBURY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 652811037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6603886950 | ||||||||
| FaxNumber: | 6603886935 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/11/2009 | ||||||||
| LastUpdateDate: | 01/13/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KELLY | ||||||||
| AuthorizedOfficialFirstName: | JACK | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5738866713 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/13/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 1245479526 | 05 | MO | MEDICAID |