Provider Demographics
NPI:1043455272
Name:SB40 TCM
Entity Type:Organization
Organization Name:SB40 TCM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:PHEGLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-546-3981
Mailing Address - Street 1:PO BOX 278
Mailing Address - Street 2:
Mailing Address - City:IRONTON
Mailing Address - State:MO
Mailing Address - Zip Code:63650-0278
Mailing Address - Country:US
Mailing Address - Phone:573-546-3981
Mailing Address - Fax:
Practice Address - Street 1:HC 1 BOX 2
Practice Address - Street 2:
Practice Address - City:MIDDLE BROOK
Practice Address - State:MO
Practice Address - Zip Code:63656-9701
Practice Address - Country:US
Practice Address - Phone:573-546-3981
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-12-02
Last Update Date:2008-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X
MO251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management