Basic Information
| Provider Information | |||||||||
| NPI: | 1447550983 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CAH ACQUISITION COMPANY 6 LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | I 70 COMMUNITY HOSPITAL- MULTI SPECIALTY CL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 105 E HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SWEET SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653512229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6603357400 | ||||||||
| FaxNumber: | 6603357487 | ||||||||
| Practice Location | |||||||||
| Address1: | 105 E HOSPITAL DR | ||||||||
| Address2: | |||||||||
| City: | SWEET SPRINGS | ||||||||
| State: | MO | ||||||||
| PostalCode: | 653512229 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6603357400 | ||||||||
| FaxNumber: | 6603357487 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/01/2010 | ||||||||
| LastUpdateDate: | 11/01/2010 | ||||||||
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| AuthorizedOfficialLastName: | GANNON | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | W | ||||||||
| AuthorizedOfficialTitleorPosition: | BUSSINESS OFFICE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 6603357407 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CAH ACQUISITION COMPANY 6 LLC | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 516-1 | MO | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1184864779 | 05 | MO | MEDICAID |