Provider Demographics
NPI:1275511859
Name:KNEIBERT CLINIC LLC
Entity Type:Organization
Organization Name:KNEIBERT CLINIC LLC
Other - Org Name:KNEIBERT NORTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:E
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-778-7210
Mailing Address - Street 1:PO BOX 220
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63902
Mailing Address - Country:US
Mailing Address - Phone:573-686-2411
Mailing Address - Fax:573-686-8452
Practice Address - Street 1:2588 N WESTWOOD BLVD
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-785-5909
Practice Address - Fax:573-785-3911
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-04
Last Update Date:2008-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO263932Medicare Oscar/Certification