Provider Demographics
NPI:1003872185
Name:MIDWEST DIVISION - LRHC LLC
Entity Type:Organization
Organization Name:MIDWEST DIVISION - LRHC LLC
Other - Org Name:ODESSA MEDICAL GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO LRHC
Authorized Official - Prefix:
Authorized Official - First Name:DARREL
Authorized Official - Middle Name:
Authorized Official - Last Name:BOX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:660-259-6852
Mailing Address - Street 1:316 WEST 40 HWY
Mailing Address - Street 2:
Mailing Address - City:ODESSA
Mailing Address - State:MO
Mailing Address - Zip Code:64076-9612
Mailing Address - Country:US
Mailing Address - Phone:816-633-5774
Mailing Address - Fax:816-633-5936
Practice Address - Street 1:316 WEST 40 HWY
Practice Address - Street 2:
Practice Address - City:ODESSA
Practice Address - State:MO
Practice Address - Zip Code:64076-9612
Practice Address - Country:US
Practice Address - Phone:816-633-5774
Practice Address - Fax:816-633-5936
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MIDWEST DIVISION - LRHC LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-04-26
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO595985805Medicaid
MO540568508Medicaid
MO010568509Medicaid
P270000Medicare PIN
MO540568508Medicaid
MO010568509Medicaid
MO595985805Medicaid