Provider Demographics
NPI:1285687509
Name:MANSFIELD CLINIC, INC.
Entity Type:Organization
Organization Name:MANSFIELD CLINIC, INC.
Other - Org Name:PRIME CARE OF AVA
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:H
Authorized Official - Last Name:DUGAN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:417-924-3066
Mailing Address - Street 1:PO BOX 108
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65704-0108
Mailing Address - Country:US
Mailing Address - Phone:417-924-3066
Mailing Address - Fax:417-924-3925
Practice Address - Street 1:120 SW 2ND AVENUE
Practice Address - Street 2:
Practice Address - City:AVA
Practice Address - State:MO
Practice Address - Zip Code:65608
Practice Address - Country:US
Practice Address - Phone:417-683-6790
Practice Address - Fax:417-683-6770
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MANSFIELD CLINIC, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-18
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO508809506Medicaid
MO000014239Medicare ID - Type Unspecified