Basic Information
| Provider Information | |||||||||
| NPI: | 1821240896 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | KNEIBERT CLINIC LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 686 LESTER ST | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639015025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736862411 | ||||||||
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| Practice Location | |||||||||
| Address1: | 686 LESTER ST | ||||||||
| Address2: | |||||||||
| City: | POPLAR BLUFF | ||||||||
| State: | MO | ||||||||
| PostalCode: | 639015025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5736862411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/21/2008 | ||||||||
| LastUpdateDate: | 10/21/2008 | ||||||||
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| AuthorizedOfficialLastName: | WARNER | ||||||||
| AuthorizedOfficialFirstName: | TOM | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | ASST ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5737787175 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QH0100X | Y | Ambulatory Health Care Facilities | Clinic/Center | Health Service |
ID Information
| ID | Type | State | Issuer | Description | 161274722 | 05 | AR | MEDICAID |