Provider Demographics
NPI:1376648725
Name:PHELPS COUNTY REGIONAL MEDICAL CENTER
Entity Type:Organization
Organization Name:PHELPS COUNTY REGIONAL MEDICAL CENTER
Other - Org Name:JUDITH CAIN
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CLINIC COORDINATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:KATHERINE
Authorized Official - Middle Name:R
Authorized Official - Last Name:HUNTER
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:573-364-2007
Mailing Address - Street 1:1206 HOMELIFE DR.
Mailing Address - Street 2:
Mailing Address - City:ROLLA
Mailing Address - State:MO
Mailing Address - Zip Code:65401
Mailing Address - Country:US
Mailing Address - Phone:357-364-2007
Mailing Address - Fax:573-364-8695
Practice Address - Street 1:1206 HOMELIFE DR.
Practice Address - Street 2:
Practice Address - City:ROLLA
Practice Address - State:MO
Practice Address - Zip Code:65401
Practice Address - Country:US
Practice Address - Phone:357-364-2007
Practice Address - Fax:573-364-8695
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:PHELPS COUNTY REGIONAL MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-09-13
Last Update Date:2008-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO20020110103T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103T00000XBehavioral Health & Social Service ProvidersPsychologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO499035616Medicaid
MO20020110OtherMO STATE
MO217270080Medicare PIN
MO499035616Medicaid