Provider Demographics
NPI:1164561890
Name:REPUBLIC R-III
Entity Type:Organization
Organization Name:REPUBLIC R-III
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DISTRICT COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:KILINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GOLDENBERG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-732-3605
Mailing Address - Street 1:518 N HAMPTON AVE
Mailing Address - Street 2:
Mailing Address - City:REPUBLIC
Mailing Address - State:MO
Mailing Address - Zip Code:65738-1323
Mailing Address - Country:US
Mailing Address - Phone:417-732-3605
Mailing Address - Fax:417-732-3609
Practice Address - Street 1:518 N HAMPTON AVE
Practice Address - Street 2:
Practice Address - City:REPUBLIC
Practice Address - State:MO
Practice Address - Zip Code:65738-1323
Practice Address - Country:US
Practice Address - Phone:417-732-3605
Practice Address - Fax:417-732-3609
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-06
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251300000XAgenciesLocal Education Agency (LEA)
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Multi-Specialty
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
No235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO506157403Medicaid