Provider Demographics
NPI:1164415030
Name:PULASKI COUNTY HEALTH DEPARTMENT
Entity Type:Organization
Organization Name:PULASKI COUNTY HEALTH DEPARTMENT
Other - Org Name:LAKE OZARK AREA HOME HEALTH & HOSPICE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DONNA
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRASHEAR
Authorized Official - Suffix:
Authorized Official - Credentials:RN, BSN
Authorized Official - Phone:573-736-2219
Mailing Address - Street 1:101 12TH STREET
Mailing Address - Street 2:
Mailing Address - City:CROCKER
Mailing Address - State:MO
Mailing Address - Zip Code:65452-9203
Mailing Address - Country:US
Mailing Address - Phone:573-736-2219
Mailing Address - Fax:573-736-5847
Practice Address - Street 1:101 12TH STREET
Practice Address - Street 2:
Practice Address - City:CROCKER
Practice Address - State:MO
Practice Address - Zip Code:65452-9203
Practice Address - Country:US
Practice Address - Phone:573-736-2219
Practice Address - Fax:573-736-5847
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PULASKI COUNTY HEALTH DEPARTMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-25
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO070-7HO251G00000X
MO00011403251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO820563005Medicaid
MO261561Medicare Oscar/Certification