Basic Information
| Provider Information | |||||||||
| NPI: | 1336800515 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWEST HEALTH SERVICES INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHILLICOTHE DENTAL CLINIC | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 803886 | ||||||||
| Address2: | |||||||||
| City: | KANSAS CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 641803886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162718265 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 300 W BUSINESS HWY 36 | ||||||||
| Address2: | |||||||||
| City: | CHILLICOTHE | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8162718265 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2022 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
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| AuthorizedOfficialLastName: | YOUNGER | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8162718265 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | NORTHWEST HEALTH SERVICES, INC. | ||||||||
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| NPICertificationDate: | 10/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | Professional | 1041C0700X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | Clinical | 1223G0001X | N | 193200000X MULTI-SPECIALTY GROUP | Dental Providers | Dentist | General Practice | 207Q00000X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 2084P0800X | N | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.