Provider Demographics
NPI:1083705529
Name:FAMILY WALK IN CLINIC OF MOUNTAIN GROVE INC
Entity Type:Organization
Organization Name:FAMILY WALK IN CLINIC OF MOUNTAIN GROVE INC
Other - Org Name:FAMILY WALK-IN CLINIC OF MTN. GROVE, INC.
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE-PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:DUGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-926-3743
Mailing Address - Street 1:205 W 3RD ST STE 3
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN GROVE
Mailing Address - State:MO
Mailing Address - Zip Code:65711-1600
Mailing Address - Country:US
Mailing Address - Phone:417-926-3743
Mailing Address - Fax:417-926-7625
Practice Address - Street 1:205 W 3RD ST STE 3
Practice Address - Street 2:
Practice Address - City:MOUNTAIN GROVE
Practice Address - State:MO
Practice Address - Zip Code:65711-1600
Practice Address - Country:US
Practice Address - Phone:417-926-3743
Practice Address - Fax:417-926-7625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2014-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO263939OtherRIVERBEND
MO596020800Medicaid