Basic Information
| Provider Information | |||||||||
| NPI: | 1790806842 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWEST HEALTH SERVICES, INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | KING CITY MEDICAL CLINIC | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 305 RHODE ISLAND | ||||||||
| Address2: | |||||||||
| City: | KING CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605354347 | ||||||||
| FaxNumber: | 6605356240 | ||||||||
| Practice Location | |||||||||
| Address1: | 305 RHODE ISLAND | ||||||||
| Address2: | |||||||||
| City: | KING CITY | ||||||||
| State: | MO | ||||||||
| PostalCode: | 64463 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6605354347 | ||||||||
| FaxNumber: | 6605356240 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/03/2007 | ||||||||
| LastUpdateDate: | 11/10/2021 | ||||||||
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| AuthorizedOfficialLastName: | YOUNGER | ||||||||
| AuthorizedOfficialFirstName: | MATT | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8162326818 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/10/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | N | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 502111271 | 05 | MO | MEDICAID |