Provider Demographics
NPI:1215368402
Name:CROSS TRAILS MEDICAL CENTER
Entity Type:Organization
Organization Name:CROSS TRAILS MEDICAL CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MONA
Authorized Official - Middle Name:
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-339-1196
Mailing Address - Street 1:1314 BRENDA AVE
Mailing Address - Street 2:
Mailing Address - City:PERRYVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63775-2624
Mailing Address - Country:US
Mailing Address - Phone:573-332-0808
Mailing Address - Fax:573-339-7945
Practice Address - Street 1:1314 BRENDA AVE
Practice Address - Street 2:
Practice Address - City:PERRYVILLE
Practice Address - State:MO
Practice Address - Zip Code:63775-2624
Practice Address - Country:US
Practice Address - Phone:573-332-0808
Practice Address - Fax:573-339-7945
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CROSS TRAILS MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-12-12
Last Update Date:2013-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)