Basic Information
| Provider Information | |||||||||
| NPI: | 1386774412 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | AREA COMMUNITY HEALTH EMISSARIES, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | ACHE DENTAL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 1136 | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 648311136 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178452243 | ||||||||
| FaxNumber: | 4178452533 | ||||||||
| Practice Location | |||||||||
| Address1: | 508 W 76 HWY | ||||||||
| Address2: | |||||||||
| City: | ANDERSON | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64831 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4178452243 | ||||||||
| FaxNumber: | 4178452533 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/07/2007 | ||||||||
| LastUpdateDate: | 06/21/2016 | ||||||||
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| AuthorizedOfficialLastName: | JAY | ||||||||
| AuthorizedOfficialFirstName: | PHYLLIS | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | GRANT MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 4178452243 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | 110 | MO | Y | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Dental Public Health |
ID Information
| ID | Type | State | Issuer | Description | 749331708 | 05 | MO | MEDICAID | 748308707 | 05 | MO | MEDICAID | 407479906 | 05 | MO | MEDICAID | 401467311 | 05 | MO | MEDICAID | 401786215 | 05 | MO | MEDICAID |