Provider Demographics
NPI:1134308026
Name:FAMILY HEALTHCARE OF AUXVASSE PC
Entity Type:Organization
Organization Name:FAMILY HEALTHCARE OF AUXVASSE PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT OWNER
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:B
Authorized Official - Last Name:KELLEY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:573-386-5959
Mailing Address - Street 1:PO BOX 190
Mailing Address - Street 2:
Mailing Address - City:AUXVASSE
Mailing Address - State:MO
Mailing Address - Zip Code:65231-0190
Mailing Address - Country:US
Mailing Address - Phone:573-386-5959
Mailing Address - Fax:573-386-5995
Practice Address - Street 1:201 S MAIN ST
Practice Address - Street 2:
Practice Address - City:AUXVASSE
Practice Address - State:MO
Practice Address - Zip Code:65231
Practice Address - Country:US
Practice Address - Phone:573-386-5959
Practice Address - Fax:573-386-5995
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-29
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO106418207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
G51497Medicare UPIN