Basic Information
Provider Information | |||||||||
NPI: | 1497141915 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | PARKLAND HEALTH CENTER - WEBER ROAD | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1101 W LIBERTY ST | ||||||||
Address2: | ADMINISTRATION | ||||||||
City: | FARMINGTON | ||||||||
State: | MO | ||||||||
PostalCode: | 636401921 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5737566451 | ||||||||
FaxNumber: | 5737569742 | ||||||||
Practice Location | |||||||||
Address1: | 1212 WEBER RD | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | MO | ||||||||
PostalCode: | 636403325 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5737564581 | ||||||||
FaxNumber: | 5737565834 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 04/10/2015 | ||||||||
LastUpdateDate: | 04/10/2015 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KARL | ||||||||
AuthorizedOfficialFirstName: | THOMAS | ||||||||
AuthorizedOfficialMiddleName: | P. | ||||||||
AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
AuthorizedOfficialTelephone: | 5737608275 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
No ID Information.