Basic Information
| Provider Information | |||||||||
| NPI: | 1356737266 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | RADOSEVICH | ||||||||
| FirstName: | FAITH | ||||||||
| MiddleName: | JUANITA EULEMA | ||||||||
| NamePrefix: | MS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1180 OLD JACKSON RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636403428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737601700 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1180 OLD JACKSON RD | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 636403428 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5737601700 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 04/19/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 04/19/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 104100000X | N | Behavioral Health & Social Service Providers | Social Worker | 183700000X | 2014033320 | MO | N | Pharmacy Service Providers | Pharmacy Technician | 376K00000X | N | Nursing Service Related Providers | Nurse's Aide | 163W00000X | 2019024085 | MO | Y | Nursing Service Providers | Registered Nurse |
No ID Information.