Basic Information
Provider Information | |||||||||
NPI: | 1922650423 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | NORTHWEST HEALTH SERVICES, INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | MID-BUCHANAN SCHOOL BASED HEALTH CENTER | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 2303 VILLAGE DR | ||||||||
Address2: |   | ||||||||
City: | SAINT JOSEPH | ||||||||
State: | MO | ||||||||
PostalCode: | 645064954 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8162326818 | ||||||||
FaxNumber: | 8162326823 | ||||||||
Practice Location | |||||||||
Address1: | 3221 SE STATE ROUTE H | ||||||||
Address2: |   | ||||||||
City: | FAUCETT | ||||||||
State: | MO | ||||||||
PostalCode: | 644488197 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8162718262 | ||||||||
FaxNumber: | 8162322991 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/15/2019 | ||||||||
LastUpdateDate: | 11/10/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | YOUNGER | ||||||||
AuthorizedOfficialFirstName: | MATT | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 8162326818 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 11/10/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.