Provider Demographics
NPI:1407954407
Name:ADVOCATES FOR A HEALTHY COMMUNITY, INC.
Entity Type:Organization
Organization Name:ADVOCATES FOR A HEALTHY COMMUNITY, INC.
Other - Org Name:JORDAN VALLEY COMMUNITY HEALTH CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KENNETH
Authorized Official - Middle Name:BROOKS
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:417-831-0150
Mailing Address - Street 1:440 E TAMPA ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65806-1131
Mailing Address - Country:US
Mailing Address - Phone:417-851-1551
Mailing Address - Fax:417-831-0155
Practice Address - Street 1:618 N BENTON AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65806-1102
Practice Address - Country:US
Practice Address - Phone:417-831-0150
Practice Address - Fax:417-831-0155
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-21
Last Update Date:2021-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO400382800Medicaid
MO500382809Medicaid