Provider Demographics
NPI:1225268618
Name:PRACTICE TEE, LLC
Entity Type:Organization
Organization Name:PRACTICE TEE, LLC
Other - Org Name:JIBBEN MEDICAL CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:JIBBEN
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:573-624-8447
Mailing Address - Street 1:PO BOX 472
Mailing Address - Street 2:
Mailing Address - City:DEXTER
Mailing Address - State:MO
Mailing Address - Zip Code:63841-0472
Mailing Address - Country:US
Mailing Address - Phone:573-624-8447
Mailing Address - Fax:
Practice Address - Street 1:1523 W BUSINESS HWY 60
Practice Address - Street 2:
Practice Address - City:DEXTER
Practice Address - State:MO
Practice Address - Zip Code:63841
Practice Address - Country:US
Practice Address - Phone:573-624-8447
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-07-20
Last Update Date:2014-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty