Provider Demographics
NPI:1164614053
Name:SAMUEL U. RODGERS HEALTH CENTER, INC.
Entity Type:Organization
Organization Name:SAMUEL U. RODGERS HEALTH CENTER, INC.
Other - Org Name:RODGERS LAFAYETTE DENTAL AND HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:HILDA
Authorized Official - Middle Name:
Authorized Official - Last Name:FUENTES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:816-889-4600
Mailing Address - Street 1:811 S BUSINESS HIGHWAY 13 STE A
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MO
Mailing Address - Zip Code:64067-1572
Mailing Address - Country:US
Mailing Address - Phone:660-259-3823
Mailing Address - Fax:660-259-4486
Practice Address - Street 1:811 S BUSINESS HIGHWAY 13 STE A
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MO
Practice Address - Zip Code:64067
Practice Address - Country:US
Practice Address - Phone:660-259-3823
Practice Address - Fax:660-259-4486
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-14
Last Update Date:2019-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO261QF0400X, 261QF0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO500859186Medicaid
MOMA1860OtherMEDICARE PTAN, WPS
MO500859186Medicaid