Provider Demographics
NPI:1154303204
Name:HAYTI MEDICAL CLINIC, INC
Entity Type:Organization
Organization Name:HAYTI MEDICAL CLINIC, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:GLENN
Authorized Official - Middle Name:
Authorized Official - Last Name:HAYNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-359-2930
Mailing Address - Street 1:223 S 3RD ST
Mailing Address - Street 2:PO BOX 37
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-1617
Mailing Address - Country:US
Mailing Address - Phone:573-359-2930
Mailing Address - Fax:573-359-1304
Practice Address - Street 1:223 S 3RD ST
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1617
Practice Address - Country:US
Practice Address - Phone:573-359-2930
Practice Address - Fax:573-359-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
263877Medicare ID - Type UnspecifiedRHC PROVIDER NUMBER