Provider Demographics
NPI:1255867479
Name:SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER
Entity Type:Organization
Organization Name:SOUTH CENTRAL MISSOURI COMMUNITY HEALTH CENTER
Other - Org Name:YOUR COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-426-6712
Mailing Address - Street 1:200 N MAIN ST
Mailing Address - Street 2:SUITE 51G
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401-3061
Mailing Address - Country:US
Mailing Address - Phone:573-426-6712
Mailing Address - Fax:573-426-6735
Practice Address - Street 1:200 N MAIN ST
Practice Address - Street 2:SUITE 51G
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401-3061
Practice Address - Country:US
Practice Address - Phone:573-426-6712
Practice Address - Fax:573-426-6735
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1164669172Medicaid